Multiple Choice Questions

Lower Limb Pathology

Please use the comments section at the bottom of the page if you have any query or feedback about any of the questions.

 

86. What are the main findings of medial tibial stress syndrome on a bone scan?

A) Delayed uptake of tracer and nonfocal uptake over the posteromedial tibial border
B) Lack of uptake of tracer in all phases
C) Focal uptake of tracer in early phase only
D) Focal uptake of tracer in delayed phases
E) Nonspecific uptake of tracer in all phases

Correct Answer: A

Medial tibial stress syndrome has a characteristic finding on bone scan of uptake only in the delayed phase. Uptake is
nonfocal and is along the posteromedial border of the tibia. These findings contrast with a stress fracture, which has
focal uptake in the early phase.

Author: Rajesh Bahadur Lakhey

 

85. Which of the following physical examination maneuvers is suggestive of piriformis syndrome?

A) Forced internal rotation of an extended thigh
B) Forced external rotation of a flexed thigh
C) Forced internal rotation of a flexed thigh
D) Forced external rotation of an extended thigh
E) Forced internal rotation of a flexed knee

Correct Answer: C

Piriformis syndrome is an uncommon ailment in which patients generally complain of posterior buttock and thigh pain.
A lumbar spine etiology must be ruled out first. Piriformis syndrome is often a diagnosis of exclusion. Few physical
examination findings suggest the diagnosis. A patient may have pain with direct palpation over the piriformis muscle,
but the more suggestive finding is pain elicited from forced internal rotation of an extended thigh.

Author: Rajesh Bahadur Lakhey

 

84. After anteromedialization of the tibial tubercle, patients with which patellar lesions were found to have better outcomes:

A) Medial facet and distal lesions
B) Lateral facet and distal lesions
C) Medial facet and proximal lesions
D) Lateral facet and proximal lesions
E) Medial and lateral facet lesions

Correct Answer: B

A study examining chondral lesions of the patella and anteromedialization of the tibial tubercle found that better results were obtained in patients with central or distal lesions and lateral facet chondral pathology than in patients with proximal patellar chondral damage.

Author: Rajesh Bahadur Lakhey

 

83. The most common technical errors when performing anterior cruciate ligament reconstruction are:

A) Excessively anterior tunnels
B) Intraoperative fracture
C) Iatrogenic posterior cruciate ligament injury
D) Excessively posterior tunnels
E) Excessively medial tunnels

Correct Answer: A

The most common technical errors involve excessively anterior placement of the tunnels. Anterior tibial tunnel and femoral tunnel placement can result in graft impingement, inability to fully extend the knee, and eventual failure.
Excessively anterior femoral tunnel placement can also result in capturing the knee with difficulty in gaining full flexion and eventual stretching or rupture of the graft with attempts at gaining full flexion.

Author: Rajesh Bahadur Lakhey

 

82. The anterior cruciate ligament is composed of which of the following bundles:

A) Anterolateral, posteromedial
B) Anteromedial, posterolateral
C) Mediolateral, posteromedial
D) Anterior, posterior
E) Medial, lateral

Correct Answer: B

The anterior cruciate ligament consists of two bundles. The anteromedial bundle is tight in flexion, and the posterolateral bundle is tight in extension

Author: Rajesh Bahadur Lakhey

 

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

A) Gastrosoleus
B) Tibialis anterior
C) Tibialis posterior
D) Peroneals
E) Flexor digitorum longus

Correct Answer: D

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

Author: Rajesh Bahadur Lakhey

 

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

A) Smaller than average cross sectional size of the ACL
B) High shoe-surface coefficient of friction
C) Smaller than average diameter of the femoral notch
D) Failure to use a knee brace
E) Failure to modify activity of female athletes during certain phases of the menstrual cycle

Correct Answer: B

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

Author: Rajesh Bahadur Lakhey

 

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

A) Anterior cruciate ligament reconstruction alone
B) Nonoperative treatment emphasizing quadriceps strengthening
C) Anterior cruciate ligament reconstruction and posterolateral corner repair
D) Anterior cruciate ligament repair and posterolateral corner repair
E) Posterolateral corner repair alone

Correct Answer: C

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

Author: Rajesh Bahadur Lakhey

 

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

A) Distally on the lateral facet
B) Proximally on the lateral facet
C) Proximally on the medial facet
D) Distally on the medial facet
E) Proximally on either facet

Correct Answer: A

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

Author: Rajesh Bahadur Lakhey

 

77. Popliteal cysts in adults are most commonly associated with which of the following knee problems:

A) Anterior cruciate ligament tears
B) Lateral meniscus tears
C) Medial meniscus tears
D) Posterior cruciate ligament tears
E) Medial collateral ligament tears

Correct Answer: C

Up to 70% of adults with popliteal cysts will have an associated medial meniscus tear vs. 20% with an associated lateral meniscus tear. Additionally, 85% of adults with a popliteal cyst will have an articular cartilage lesion.

Author: Rajesh Bahadur Lakhey

 

76. The primary intervention for patients with medial tibial stress syndrome is:

A) Surgery with release of the posteromedial fascia
B) Cortisone injections at the insertion of the soleus on the posteromedial tibia
C) Viscosupplementation of the knee
D) Activity modification, icing after activities, and nonsteroidal anti-inflammatory medication
(E) Increasing activities until pain subsides

Correct Answer: D

Most cases of medial tibial stress syndrome resolve with relative rest and icing after activities. Nonsteroidal antiinflammatory medications may also be useful. Cortisone injections and viscosupplementation do not play a role in
medial tibial stress syndrome. Surgery for medial tibial stress syndrome includes release of the soleus fascia; however, surgery is rarely indicated.

Author: Rajesh Bahadur Lakhey

 

75. Which of the following is the most commonly injured knee ligament? 

A) Lateral collateral ligament
B) Medial collateral ligament
C) Anterior cruciate ligament
D) Posterior cruciate ligament
E) Falciform ligament

Correct Answer: B

The medial collateral ligament is the most commonly injured ligament of the knee. Generally, these injuries are treated nonoperatively and many are overlooked or not diagnosed by a physician. Anterior cruciate ligament injuries are the second most common injury, but they most often result in surgical reconstruction. Posterior cruciate ligament injuries are less common but are under-recognized.

Author: Rajesh Bahadur Lakhey

 

74. The reported 3- to 5-year success rate of a chondral lesion microfracture technique in the knee is:

A) 10% improvement
B) 25% improvement
C) 40% improvement
D) 75% improvement
E) 95% improvement

Correct Answer: D

Steadman and colleagues reported a 75% improvement at 3- to 5-year follow-up using the microfracture technique with arthroscopic awls.

Author: Rajesh Bahadur Lakhey

 

73. The magnetic resonance image (MRI) of a 16-year-old high school football player who sustained a knee injury
during a game is presented (Slide). He reports mild swelling at the time of injury but does not recall hearing a “pop.”
He has attempted to return to football but is unable to make side-to-side movements. On clinical examination, no difference in anterior or posterior laxity is appreciated when comparing the injured knee to the uninjured knee. 

What is the most appropriate initial management?

A) Open reduction internal fixation of the tibial plateau fracture
B) Percutaneous fixation of the tibial plateau fracture
C) Medial patellofemoral ligament reconstruction
D) Medial collateral ligament repair
E) Functional rehabilitation with progressive return to play

Correct Answer: E

The MRI demonstrates an isolated injury to the medial collateral ligament with an associated lateral tibial plateau bone contusion. Appropriate initial management consists of functional rehabilitation with progressive return to play.

Author: Rajesh Bahadur Lakhey

 

72. In the literature, the patella redislocation rate for conservatively treated patients ranges from:

A) 5% to 10%
B) 10% to 20%
C) 15% to 45%
D) 40% to 70%
E) 75% to 90%

Correct Answer: C

The patella redislocation rate for conservatively treated patients ranges from 13% to 44% in the literature. The treatment varies from casting to an elastic bandage and early range of motion

Author: Rajesh Bahadur Lakhey

 

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

A) Posterior, anterior
B) Anterior, posterior
C) Anterior, anterior
D) Posterior, posterior
E) Medial, lateral

Correct Answer: B

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

Author: Rajesh Bahadur Lakhey

 

70. In the posterior cruciate ligament the anterolateral bundle is tight in ______ and the posteromedial
bundle is tight in

A) Flexion, extension
B) Extension, flexion
C) Extension, extension
D) Flexion, flexion
E) Neither bundle tightens throughout the knee’s range of motion.

Correct Answer: A

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

Author: Rajesh Bahadur Lakhey

 

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

A) Better range of motion at the 2-year follow-up
B) Better knee stability at the 2-year follow-up
C) Better knee function at the 2-year follow-up
D) More knee pain at the 3-month follow-up
E) More quadriceps atrophy at the 3-month follow-up

Correct Answer: E

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

Author: Rajesh Bahadur Lakhey

 

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

A) 10 mm Hg
B) 15 mm Hg
C) 20 mm Hg
D) 25 mm Hg
E) 30 mm Hg

Correct Answer: B

The criteria for diagnosing chronic exertional compartment syndrome from compartment pressure measurements
include one or more of the following:
* More than or equal to 15 mm Hg resting pressure
* A 1-minute postexercise pressure of more than or equal to 30 mm Hg
* A 5-minute postexercise pressure of more than or equal to 20 mm Hg

Author: Rajesh Bahadur Lakhey

 

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

A) Full objective strength
B) Return to sport at a lower level of play for most athletes
C) Return to full sports for most athletes despite decreased objective adductor strength
D) Inability to return to sports
E) Unacceptable complication rates

Correct Answer: C

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

Author: Rajesh Bahadur Lakhey

 

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

A) Anterolateral bundle
B) Anteromedial bundle
C) Posteromedial bundle
D) Posterolateral bundle
E) Anterolateral and posteromedial equally

Correct Answer: A

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

Author: Rajesh Bahadur Lakhey

 

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

A) Culture-specific intravenous antibiotics
B) Culture-specific intravenous antibiotics and surgical irrigation with graft retention
C) Culture-specific intravenous antibiotics and surgical irrigation with graft removal
D) Culture-specific intravenous antibiotics, surgical irrigation with graft removal, and immediate revision reconstruction
E) Culture-specific intravenous antibiotics, surgical irrigation with graft removal, and delayed revision reconstruction

Correct Answer: B

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

Author: Rajesh Bahadur Lakhey

 

64. Patellar tendinitis is associated with:

A) Pain at the insertion of the patellar tendon on the tibia
B) Pain at the insertion of the patellar tendon on the patella
C) Lateral knee pain during downhill running
D) Locking and popping of the knee during activity
E) “Giving way” of the knee during activity

Correct Answer: B

Activities such as basketball, soccer, volleyball and track require repeated impact with the ground. This leads to microtrauma, resulting in degeneration of the tendon and focal inflammation. Pain at the inferior pole of the patella is usually isolated with palpation along the tip of the kneecap.

Author: Rajesh Bahadur Lakhey

 

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

A) Outerbridge’s ridge
B) Blumensatt’s line
C) Notch of Grant
D) David’s point
E) Sulcus terminalis

Correct Answer: E

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

Author: Rajesh Bahadur Lakhey

 

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

A) 5° to 10°
B) 10° to 15°
C) 15° to 20°
D) 20° to 25°
E) 25° to 30°

Correct Answer: C

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

Author: Rajesh Bahadur Lakhey

 

61. In anterior cruciate ligament (ACL) rehabilitation, closed-chain kinetic exercises are associated with all of the following except: 

Recommended initial management includes:

A) Allow for co-contraction of the musculature around the knee
B) Stabilize the foot
C) Allow hip muscular activity for stability
D) Apply physiologic compressive loads to the knee
E) Improve aerobic power and endurance in the leg

Correct Answer: E

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

Author: Rajesh Bahadur Lakhey

 

60. A magnetic resonance image (MRI) of the left hip of a 26-year-old female triathlete with progressive pain is shown . Recommended initial management includes:

A) Percutaneous fixation with cannulated screws
B) Resumption of activities as tolerated
C) Incisional biopsy
D) Fixation with a dynamic hip screw
E) A period of nonweight bearing with further workup including nutritional and menstrual history

Correct Answer: E

The MRI demonstrates an incomplete compression-sided femoral neck stress fracture. Appropriate initial management is a period of nonweight bearing as well as assessment of risk factors (e.g., poor nutrition and amenorrhea) for additional stress fractures. Tension-sided and complete femoral neck stress fractures should be treated with fixation to avoid fracture displacement and to promote union

Author: Rajesh Bahadur Lakhey

 

59. The magnetic resonance image in this distance runner (Slide) reveals:

A) Iliopsoas tendinitis
B) Hip flexor injury
C) Pelvic stress fracture
D) Femoral neck stress fracture
E) Subtrochanteric stress fracture

Correct Answer: D

The magnetic resonance image reveals a compression side femoral neck stress reaction. A compression side femoral neck stress reaction should be treated with restricted weight bearing to a pain free level. If the reaction/fracture progresses to more than 50% involvement of the neck, it can be treated with percutaneous screw fixation to avoid the disastrous complication of a displaced femoral neck stress fracture.

Author: Rajesh Bahadur Lakhey

 

58. Which of the following represents the most common scenario of injury resulting in athletic pubalgia:

A) Repetitive hyperextension of the trunk in association with hyperabduction of the thigh pivoting on the anterior pelvis and pubic symphysis in a female athlete
B) Repetitive hyperextension of the trunk in association with hyperabduction of the thigh pivoting on the anterior pelvis and pubic symphysis in a male athlete
C) A single forced hyperextension of the trunk in association with hyperabduction of the thigh pivoting on the anterior pelvis and pubic symphysis in a female athlete
D) A single forced hyperextension of the trunk in association with hyperabduction of the thigh pivoting on the anterior pelvis and pubic symphysis in a male athlete
E) A single forced hyperflexion of the trunk in association with hyperabduction of the thigh pivoting on the anterior pelvis and pubic symphysis in a male athlete

Correct Answer: B

The rectus insertion on the pubis with or without the origin of the adductor longus tendon appears to be the primary site of pathology. Athletic pubalgia has been described primarily in high-level athletes and almost exclusively in men. The proposed mechanism of injury involves repetitive hyperextension of the trunk in association with hyperabduction of the thigh pivoting on the anterior pelvis and pubic symphysis.

Author: Rajesh Bahadur Lakhey

 

57. What is the name of the sign elicited with the test for piriformis syndrome:

A) Wilson’s sign
B) McMurray’s sign
C) Pellegrini-Stieda sign
D) Hoffman’s sign
E) Pace’s sign

Correct Answer: E

Pace’s sign is the name given to pain elicited with forced internal rotation of a flexed hip and is suggestive of piriformis syndrome if patient history correlates with the examination. Wilson’s sign is associated with osteochondritis dissecans of the knee. McMurray’s sign is associated with meniscus tears of the knee. Pellegrini-Stieda sign refers to a radiographic finding of chronic medial collateral ligament injuries. Hoffman’s sign is associated with cervical stenosis.
Pellegrini-Stieda sign refers to a radiographic finding of chronic medial collateral ligament injuries. Hoffman’s sign is associated with cervical stenosis.

Author: Rajesh Bahadur Lakhey

 

56. Where is the primary pathology site for athletic pubalgia?

A) Sartorius origin
B) Rectus abdominus origin
C) Rectus abdominus insertion
D) Inguinal canal
E) Ischial tuberosity

Correct Answer: C

The primary pathology site of athletic pubalgia is believed to be the rectus abdominus insertion on the pubis. This is a diagnosis of exclusion and some authors question its existence. An athlete generally has pain in the lower abdominal and groin area. A hernia is not present and, generally, patients fail a course of conservative management of a groin strain before the diagnosis is made. Patients generally have pain with palpation at the rectus abdominus insertion on the pubis. Surgical management involves an open Bassini hernia repair.

Author: Rajesh Bahadur Lakhey

 

55. Which of the following is the main advantage of an all-inside meniscus repair compared to an inside-out repair:

A) Cheaper implants
B) Biomechanically superior repair
C) Ease of use, less operative time, and no incision
D) Fewer implant complications
E) Better long-term results

Correct Answer: D

The main advantages to all-inside repair are ease of use, less operative time, and lack of an incision. Currently, there are still complications with implants, but these are improving over time. The vertical mattress suture of an inside-out repair is still superior to an all-inside implant biomechanically, but the newer generation of implants is improving. Although an inside-out technique is biomechanically superior, several studies indicate equivalent outcomes between all-inside and inside-out techniques.

Author: Rajesh Bahadur Lakhey

 

54. Which of the following structures is most commonly injured in conjunction with a posterior cruciate ligament rupture?

A) Anterior cruciate ligament
B) Posterolateral corner
C) Medial collateral ligament
D) Lateral meniscus
E) Patellar tendon

Correct Answer: B

The posterolateral corner is most often associated with posterior cruciate ligament injuries. Patients who fail
conservative management of posterior cruciate ligament injuries often have an associated posterolateral corner injury.

Author: Rajesh Bahadur Lakhey

 

53. Which of the following structures is the major stabilizer of the knee to valgus stress at 30°:

A) Posterior oblique ligament
B) Deep medial collateral ligament
C) Superficial medial collateral ligament
D) Medial meniscus
E) Anterior cruciate ligament

Correct Answer: C

The major stabilizer of the knee to valgus load at 30° of flexion is the superficial medial collateral ligament. The deep medial collateral ligament and the posterior oblique ligament also contribute to stability of the knee, but they are not as important as the superficial medial collateral ligament at 30°. The anterior cruciate ligament plays a secondary role in valgus stability; however, it functions mostly in full extension.

Author: Rajesh Bahadur Lakhey

 

52. Meniscus repair is most successful for tears in which of the following zones:

A) Red-blue zone
B) Red-red zone
C) Red-white zone
D) White-white zone
E) White-red zone

Correct Answer: B

The microvascular anatomy of the meniscus was initially defined by Arnoczky and Warren in 1982. They demonstrated that the perimeniscal capillary plexus supplies the most peripheral region of the meniscus with blood and that this blood supply is centrally insufficient. Their finding accurately predicted that peripheral tears would have a better chance of healing than more central tears. Subsequently, the menisci were divided into three regions based upon the blood supply. These three regions are the red-red zone (peripheral third), the red-white zone (middle third), and the white-white zone (central third). The zone names correlate with the rich peripheral and poor central blood supply.

Author: Rajesh Bahadur Lakhey

 

51. A magnetic resonance image (MRI) of a 15-year-old female volleyball player who twisted her knee is shown (Slide). Despite 6 weeks of rehabilitation, she has been unable to return to volleyball without having her knee give out. 

What is the most appropriate treatment?

A) Anterior cruciate ligament reconstruction
B) Posterior cruciate ligament reconstruction
C) Continued physical therapy
D) Use of a knee brace
E) Medial patellofemoral ligament reconstruction

Correct Answer: A

The MRI clearly shows disruption of the femoral attachment of the anterior cruciate ligament with characteristic joint effusion. The most appropriate treatment for the patient in this scenario is anterior cruciate ligament reconstruction.

Author: Rajesh Bahadur Lakhey

 

50. The recommended treatment for patients with chronic exertional compartment syndrome is:

A) Stretching and strengthening program
B) Activity modification
C) Fasciotomy
D) Ultrasound
E) Steroid injections to reduce muscle swelling

Correct Answer: B

Unless patients are willing to avoid the offending activity, nonoperative management of chronic exertional
compartment syndrome is unsuccessful. The surgical management involves fasciotomy of the affected compartments.

Author: Rajesh Bahadur Lakhey

 

49. The differential diagnosis for chronic exertional compartment syndrome includes all of the following except:

A) Tibial stress fracture
B) Medial tibial periostalgia
C) Popliteal artery entrapment
D) Fascial herniations
E) Femoral neck stress fracture

Correct Answer: E

The differential diagnosis for chronic exertional compartment syndrome includes stress fractures, medial tibial
periostalgia, tendinitis, nerve entrapment disorders, fascial herniations, vascular or neurogenic claudication, popliteal artery entrapment, and venous stasis.

Author: Rajesh Bahadur Lakhey

 

48. The healing rate of meniscal repairs in association with acute anterior cruciate ligament (ACL) reconstruction
is_______ that reported for isolated meniscal repairs:

A) Higher than
B) Lower than
C) Equal to
D) Meniscal repairs are not recommended in this situation
E) Unknown

Correct Answer: A

The results with respect to healing of meniscal repairs in the association of an acute ACL injury are reported to be better than in other situations (92% vs 67%).

Author: Rajesh Bahadur Lakhey

 

47. Which of the following positions of knee flexion produces the greatest strain in the anterior cruciate ligament with anterior loading of the tibia:

A) 30° (Lachman test)
B) 45°
C) 55°
D) 75°
E) 90° (anterior drawer test)

Correct Answer: A

Clinical and biomechanical studies show that anterior loading of the tibia in 30° of knee flexion produces greater strain and elongation of the normal anteromedial bundle than loading in 90° of knee flexion.

Author: Rajesh Bahadur Lakhey

 

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

A) A palpable defect 3 cm to 4 cm proximal to the Achilles insertion
B) Ability to plantarflex the foot against gravity
C) Sensation of being kicked in the calf
D) Plantarflexion of the foot with the Thompson test
E) No previous symptoms of Achilles related pain

Correct Answer: D

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

Author: Rajesh Bahadur Lakhey

 

45. Patients with symptomatic chronic proximal hamstring ruptures typically complain of:

A) Anterior thigh cramping with running
B) Difficulty decelerating the leg during running
C) Difficulty ascending stairs
D) Difficulty descending stairs
E) Difficulty accelerating the leg during running

Correct Answer: B

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

Author: Rajesh Bahadur Lakhey

 

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

Which of the following should be included in her initial treatment regimen:

A) Treatment with nonsteroidal anti-inflammatory medications
B) Localized steroid injection
C) Intramedullary nailing with bone grafting
D) Continuation of current training regimen
E) Initiation of hormone replacement therapy

Correct Answer: E

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

Author: Rajesh Bahadur Lakhey

 

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

Recommended treatment includes:

A) Arthroscopic debridement
B) Open reduction internal fixation
C) Percutaneous pinning in situ
D) Period of nonweight bearing with continued observation
E) Continuation of current training regimen

Correct Answer: D

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

Author: Rajesh Bahadur Lakhey

 

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

A) 5%
B) 10%
C) 30%
D) 75%
E) More than 90%

Correct Answer: C

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

Author: Rajesh Bahadur Lakhey

 

41. Sectioning the posterolateral structures and posterior cruciate ligament results in:

A) Increased posterior tibial translation at 30°
B) Increased posterior tibial translation at 90
C) Increased posterior tibial translation at 30° and 90°
D) No increase in tibial translation
E) Increased anterior tibial translation at 30° and 90° 

Correct Answer: C

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

Author: Rajesh Bahadur Lakhey

 

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

A) The biceps tendon and fabellofibular ligament
B) The patellofemoral ligaments and quadriceps retinaculum
C) The iliotibial tract and biceps tendon
D) The joint capsule and fabellofibular ligament
E) The popliteofibular ligament and biceps tendon

Correct Answer: C

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

Author: Rajesh Bahadur Lakhey

 

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

A) Tenderness over the pubic tubercle
B) Inguinal hernia
C) Tenderness to palpation of the adductor longus
D) Pain with resisted hip adduction
E) Pain with resisted sit-ups

Correct Answer: D

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

Author: Rajesh Bahadur Lakhey

 

38. The initial management of athletic pubalgia consists of:

A) Modified Bassini hernia repair
B) Adductor release
C) Hip arthroscopy
D) Core trunk stabilization and rest
E) Laparoscopic hernia repair

Correct Answer: D

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

* Reattachment of the inferolateral edge of the rectus using a modified Bassini repair has resulted in
return to sports activities for the majority of patients, but the procedure should follow a nonoperative
trial.
* Adductor release can be part of the operative approach after failure of nonoperative management.
* Hip joint pathology is not consistently associated with athletic pubalgia.

Author: Rajesh Bahadur Lakhey

 

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

A) Lateral superior geniculate artery
B) Medial superior geniculate artery
C) Middle geniculate artery
D) Medial inferior geniculate artery
E) Lateral inferior geniculate artery

Correct Answer: C

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

Author: Rajesh Bahadur Lakhey

 

36. All of the following factors have a significant influence on the long-term anteroposterior (AP) laxity of the knee
following anterior cruciate ligament (ACL) reconstruction except:

A) Integrity of the medial meniscus
B) Graft tunnel placement
C) Graft tissue selection
D) Timing of surgery following injury
E) Graft elongation behavior at the time of reconstruction

Correct Answer: A

Although the integrity of the medial meniscus (particularly the posterior horn) has provided some AP stability in the ACL-deficient knee, there is no evidence that this holds true in the knee that has undergone reconstruction of the ACL.

Graft tunnel placement, graft tissue selection, and time from injury to reconstruction have been shown to directly affect the long-term AP stability of the reconstructed knee. Recent data have revealed that patients whose graft elongation behavior at the time of ACL reconstruction closely approximated that of the normal ACL had better AP stability at 5-year follow-up than patients whose graft elongation behavior was different from the native ACL.

Author: Rajesh Bahadur Lakhey

 

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

A) Popliteal artery
B) Popliteal vein
C) Saphenous nerve
D) Sural nerve
E) Popliteus tendon

Correct Answer: C

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

Author: Rajesh Bahadur Lakhey

 

34. When performing elbow arthroscopy, the arthroscopic portal that must be established first is the:

A) Anteromedial portal
B) Anterolateral portal
C) Lateral portal
D) Posterolateral portal
E) Posterior portal

Correct Answer: A

The anteromedial portal is the farthest from the neurovascular structures of the elbow and is the safest to establish. After this portal is established, the joint can be distended, increasing the distance of the other portal sites from the neurovascular structures.

Author: Rajesh Bahadur Lakhey

 

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

The next most appropriate course of action is:

A) Obtain an magnetic resonance image
B) Steroid injection to the right knee
C) Arthroscopic debridement of the right lateral meniscus
D) Arthroscopic repair of the right lateral meniscus
E) Stretching of the right iliotibial band, temporary decrease in mileage, and anti-inflammatory medication

Correct Answer: E

The patient has iliotibial band friction syndrome, which is common in runners. Physical therapy is successful in
the majority of patients. Rarely, debridement of an ellipse of the iliotibial band will be required to provide relief.

Author: Rajesh Bahadur Lakhey

 

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

A) Allograft sterilization using gamma irradiation has not been shown to adversely affect its tensile properties.
B) Allograft use avoids donor site morbidity.
C) Allograft use diminishes postoperative pain.
D) Allograft use decreases surgical time.
E) Allograft incorporation is slower than autograft.

Correct Answer: A

Secondary sterilization is achieved with the use of ethylene oxide or gamma irradiation, both of which have
detrimental effects on the allograft. Ethylene oxide residues remain on the tissue and stimulate an intra-articular reaction. Gamma radiation has been shown to decrease structural and mechanical properties of the tissue. Irradiation also alters the collagen morphology of sterilized tissues. 

Currently, the most accepted method of allograft sterilization involves sterile harvesting and deep freezing.

Author: Rajesh Bahadur Lakhey

 

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

A) Cortisone injection into the site of tenderness
B) Use of a knee immobilizer for 6 weeks
C) Nonsteroidal anti-inflammatory medication and quadriceps stretching exercises
D) Arthroscopic lateral release
E) Open patellar tendon debridement

Correct Answer: C

This scenario is consistent with infrapatellar tendinitis (jumper’s knee), which is common in runners and
jumpers. The mechanism often involves chronic overloads of the tendon. Anti-inflammatory medication may
alleviate symptoms while quadriceps stretching decreases the load on the tendon by increasing the resting
length of the muscle-tendon unit. 

Open patellar tendon debridement should be reserved for cases of chronic tendonitis that are refractory to conservative management.

Author: Rajesh Bahadur Lakhey

 

30. All of the disorders listed below are examples of osteochondrosis except:

A) Legg-Calvé-Perthes disease
B) Scheuermann’s disease 
C) Osgood Schlatter disorder 
D) Gorham’s disease
E) Blount disease

Correct Answer: D

The term osteochondrosis refers to symptomatic disorders involving cartilage growth. Cartilage affected by osteochondrosis may be epiphyseal, physeal, or apophyseal. Gorham’s disease is not an example of osteochondrosis. Gorham’s disease is a lymphatic disorder known as disappearing bone disease.

Author: Fouad Chaudery

 

29. What is the histological difference between avascular necrosis of the femoral head in children versus adults ?

A) Children have less creeping substitution than adults
B) Children do not demonstrate osseous collapse. 
C) Large areas of fibrovascular tissue do not form in children. 
D) There is no osteoclastic resorption in children. 
E) Children do not have any residual changes after 2 years. 

Correct Answer: A

Avascular necrosis models of the femoral head in immature animals show more osteoclastic resorption, fibroblastic response, and little creeping substitution when compared to models of mature animals. Osseous collapse is common, and there are often long-term residual changes in the shape of the femoral head.

Author: Fouad Chaudery

 

28. The result of treatment of developmental dysplasia of the hip with Salter osteotomy is is worse with which of the following:

A) A higher degree of the dislocation before treatment (Tonnis grade)
B) Bilaterality 
C) Higher preoperative acetabular index
D) Increased age at surgery 
E) Performing open reduction at a separate surgery than the osteotomy

Correct Answer: A

Salter osteotomy is effective in treating developmental dysplasia of the hip in young children. The result is worse with higher degrees of dislocation as assessed by the Tonnis system. It is better if the open reduction (if needed) is performed as a separate step than the osteotomy. The other factors have not been shown to be predictive.

Author: Fouad Chaudery

 

27. Which of the following is an appropriate position for arthrodesis of the hip in a young person:

A) Flexion of 45°
B) Abduction of 15° if there is shortening
C) Adduction of 0°
D) External rotation of 25° 
E) Shortening of at least 3 cm

Correct Answer: C

Neutral abduction is important in preventing back pain.

• The flexion should be between 25° and 35°.
• Any abduction beyond neutral poses increased risk of back pain.
• External rotation beyond approximately 5° is not needed.
• Arthrodesis often produces some mandatory shortening; therefore, intentional shortening is not needed.

Author: Fouad Chaudhry

 

26. Osteochondral defects occur bilaterally in the distal femur in approximately:

A) 10% to 20% of patients. 
B) 20% to 30% of patients. 
C) 30% to 40% of patients.
D) 60% to 70% of patients. 

Correct Answer: B

Osteochondral defects occur bilaterally in the distal femur for approximately 20% to 30% of patients. The fact that 20% to 30% of patients with an osteochondral lesion in the distal femur have bilateral involvement suggests that there is a predisposition to the development of a lesion at this location, either genetic or secondary to repetitive microtrauma.

Author: Fouad Chaudhry


25. A patient underwent bone-patellar-bone anterior cruciate ligament reconstruction. Postoperative radiographs show the femoral tunnel has been placed too far anteriorly. 

What is the most likely clinical result of anterior placement of the femoral tunnel?

A) Limited extension
B) Anterior instability
C) Anterior knee pain
D) Limited flexion
E) Posterior instability

Correct Answer: A

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

Author: Fouad Chaudhry

 

24. In the setting of chronic anterior cruciate ligament (ACL) deficiency .

which of the following meniscal tear patterns is most common:

A) Peripheral posterior horn tears of the medial meniscus
B) Peripheral posterior horn tears of the lateral meniscus
C) Peripheral anterior horn tears of the medial meniscus
D) Peripheral anterior horn tears of the lateral meniscus
E) Central posterior horn tears of the medial meniscus

Correct Answer: A

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

Author: Fouad Chaudhry

 

23. After landing awkwardly on his flexed knee, a 22-year-old basketball player has immediate onset of pain and difficulty bearing weight. With the knee flexed 30°, examination reveals increased varus, external rotation, and posterior translation which decreases when the knee is flexed to 90°. 

The patient most likely has injured what structures:

A) Posterolateral complex
B) Posterolateral complex and posterior cruciate ligament
C) Posterior cruciate ligament
D) Lateral collateral ligament
E) Posterior cruciate ligament and medial collateral ligament

Correct Answer: A

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

Author: Fouad Chaudhry

 

22. Which tear pattern is most responsive to meniscus repair:

A) Radial
B) Complex
C) Parrot beak
D) Longitudinal
E) Horizontal Cleavage

Correct Answer: D

Longitudinal tears are the most responsive tear pattern to successful repairs. Longitudinal tears occur in the plane of the radial orientation of the meniscal infrastructure. Other patterns of tears disrupt this radial orientation, resulting in high stress across the repair site and difficulty in reconstituting lost meniscal function

Author: Fouad Chaudhry

 

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

A) At the level of the tibial plateau
B) 0 mm to 5 mm inferior to the level of the tibial plateau
C) 5 mm to 10 mm inferior to the level of the tibial plateau
D) 10 mm to 15 mm inferior to the level of the tibial plateau
E) 15 mm to 20 mm inferior to the level of the tibial plateau

Correct Answer: D

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

Author: Fouad Chaudhry

 

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

A) Posterior cruciate ligament 
B) Anterior cruciate ligament 
C) Medial collateral ligament 
D) Lateral collateral ligament 
E) Posterolateral corner 

Correct Answer: B

The posterior cruciate ligament is the primary stabilizer to posterior translation of the knee. 

Secondary stabilizers include the medial and lateral collateral ligaments and the posterolateral corner.

Author: Fouad Chaudhry

 

19. Placing a highly tensioned soft tissue graft across the open femoral physis during anterior cruciate ligament reconstruction results in which of the following outcomes

A) Premature closure of the physis 
B) No growth disturbance 
C) Development of femoral varus 
D) Development of femoral valgus 
E) Femoral overgrowth 

Correct Answer: D

An excessively tensioned soft tissue graft placed across the  femoral physis causes inhibition of growth of the lateral aspect of the distal femur resulting in the development of femoral valgus. The physis remains open during this process. Although this canine model illustrates potential harm that may result in a similar situation the human, the precise clinical implications of this canine model are unclear at this time. 

Author: Fouad Chaudhry

 

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

A) Posterior cruciate ligament 
B) Anterior cruciate ligament 
C) Medial collateral ligament 
D) Lateral collateral ligament 
E) Posterolateral corner 

Correct Answer: B

The posterior cruciate ligament is the primary stabilizer to posterior translation of the knee. 

Secondary stabilizers include the medial and lateral collateral ligaments and the posterolateral corner.

Author: Fouad Chaudhry

 

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

A) An increase of the medial joint space on radiograph 
B) Intermediate or long-term symptomatic improvement in the majority of patients 
C) Formation of a fibrocartilage articular surface 
D) Formation of primarily type I collagen 
E) Worsening of symptoms in 10% to 20% of patients 

Correct Answer: B

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

Author: Fouad Chaudhry

 

14. In which of the following anatomic locations have authors described a characteristic osteochondral lesion that occurs with an acute anterior cruciate ligament (ACL) injury:

A) Posterolateral aspect of the tibia and the anterolateral aspect of the lateral femoral condyle 
B) Posterolateral aspect of the tibia and the posterolateral aspect of the lateral femoral condyle 
C) Lateral patellar facet and lateral trochlear groove 
D) Anterolateral aspect of the tibia and the posterolateral aspect of the lateral femoral condyle 
E) Posteromedial aspect of the tibia and the anteromedial aspect of the lateral femoral condyle 

Correct Answer: A

During anterior cruciate ligament (ACL) injury, anterior translation of the tibia and the associated valgus force create a compressive load on the articular cartilage in the posterolateral aspect of the tibia and the anterolateral aspect of the lateral femoral condyle. 

It has been estimated that approximately 80% of acute ACL injuries demonstrate this pattern on magnetic resonance imaging.

Author: Fouad Chaudhry

 

13. Which of the following processes may produce cystic bone erosions in the cortex on both sides of a joint:

A) Septic Arthritis
B) Synovial chondormatosis
C) Pigmented villonodular synovitis 
D) Ochronosis
E) Hemochromatosis

Correct Answer: C

Pigmented villonodular synovitis is a synovial proliferative disorder characterized by atraumatic recurrent effusions and cystic erosions of the periarticular bone surfaces. The synovial tissue becomes hypertrophic and can cause large erosions on both sides of the joint. These erosions most commonly occur in the hip joint because of the tight capsule and the limited amount of space for extension of the disease. Conversely, in the knee, there is room for expansion and these erosions occur late in the disease.

Author: Fouad Chaudhry

 

12. A 40y old man has had hip pain with increased activity over the past year. Examination reveals restriction of motion and tenderness with combined hip fl exion, adduction, and internal rotation. An AP radiograph is shown in the figure attached. 

What is the most likely diagnosis?

A) Developmental dysplasia of the hip
B) Osteonecrosis
C) Pseudogout
D) Femoral acetabular impingement                                                                                                                                                                                              E) Perthes disease                                                

The correct answer is : D

Femoral acetabular impingement (FAI) is a pathologic entity leading to pain, reduced range of motion in fl exion and internal rotation, and development of sec-ondary arthritis of the hip. There are two types of FAI: cam impingement and pincer impingement. 

Cam impingement is seen when a nonspherical femoral head pro-duces a cam effect when the prominent portion to the femoral head rotates into the joint. This mechanism produces shear forces that damage articular cartilage. Radiographs reveal early joint degeneration and fl attening of the head neck junction (pistol grip deformity) as seen in this image. 

The pincer type of impingement involves abnormal contact between the femoral head neck junction and the acetabulum, in the presence of a spherical femoral head.

Author : Salam Al-Abayachi

 

11. Bleeding is encountered while developing the internervous plane between the tensor fascia lata and the sartorius during the anterior approach to the hip. 

The most likely cause is injury to what artery?

A) Ascending branch of the lateral femoral circumf ex
B) Superior gluteal
C) Femoral
D) Profunda femoris
E) Medial femoral circumfl ex

The correct answer is : A

The ascending branch of the lateral femoral circumfl ex artery crosses the gap between the tensor fascia lata and the sartorious and must be identifi ed and ligated or coagulated. The other ves-sels are out of the f eld of dissection.

Author : Salam Al-Abayachi

 

10. Which of the following images is best for detecting anterior acetabular deficiency in the dysplastic hip?

A) Pelvic inlet
B) Judet
C) AP pelvis
D) False profile
E) Frog lateral

The correct answer is : D

The false profi le view of Lequesne and de Seze is obtained with the patient standing with the affected hip on the cassette, the ipsilateral foot parallel to the cassette, and the pelvis rotated 65° from the plane of the cassette. This view best assesses anterior coverage of the femoral head.

Author : Salam Al-Abayachi

 

9. At the level of tibial bone resection in TKA, where does the common peroneal nerve lie?

A) Deep to the arcuate ligament
B) Closer to bone in larger legs
C) On the muscle belly of the popliteus
D) On the bony posterolateral corner of the tibia
E) Superficial to the lateral head of the gastrocnemius

The correct answer is : E

At the level of tibial bone resection in total knee arthroplasty, the common peroneal nerve lies superfi cial to the lateral head of the gastrocnemius and is therefore protected by this structure. In an MRI study of 60 knees, the mean distance from the bony posterolateral corner of the tibia to the nerve was 1.49 cm, with no distance less than 0.9 cm. The distance from the bone to nerve was greater in larger legs.

Author : Salam Al-Abayachi

 

8. What complication is more likely following excessive medial retraction of the anterior  structures during the anterolateral (Watson-Jones) approach to the hip?

A) Numbness over the anterolateral thigh
B) Ischemia to the leg
C) Quadriceps weakness
D) Abductor insufficiency
E) Foot drop

The correct answer is : C

The femoral nerve is the most lateral structure in the anterior neurovascular bundle. The femoral artery and vein lie medial to the nerve. Retractors placed in the anterior acetabular lip should be safe, although neurapraxia of the femoral nerve may occur if retraction is prolonged or forceful lead-ing to quadriceps weakness. The femoral artery and nerve are well protected by the interposed psoas muscle. Damage to the lateral femoral cutaneous nerve, causing numbness over the anterolateral thigh, can occur while developing the interval between the tensor fascia latae and sartorious in the anterior (Smith-Petersen) approach but less likely in the Watson-Jones approach. Superior gluteal injury and accompanying abductor insuffi ciency may occur during excessive splitting of the glutei during the direct lateral (Hardinge) approach. Foot drop secondary to sciatic injury is more common with a posterior exposure or posterior retractor placement.

Author : Salam Al-Abayachi

 

7. Trenderburg’ s sign can be elicited in all of the following except :

Trendelenburg test or sign | Epomedicine
A) Congenital dislocation of the hip.
B) Infantile paralysis of the gluteal muscles.
C) Coxa vara.
D) Tuberculous arthritis of the hip joint.
E) Non-united fracture of the femoral neck.

The correct answer is : D

Several dysfunctions can produce a positive Trendelenburg Test:
1-Weakness of gluteus medius.
2-Hip instability and subluxation.
3-Hip osteoarthritis.
4-Initially, post Total Hip Replacement.
5-Superior Gluteal Nerve Palsy.
6-Lower back pain.
7-Legg-Calvé-Perthes Disease.
8-Congenital hip dislocation.

Author : Firas Arnaout

 

6.  A football player fell on his flexed knee with the foot in plantar flexion. On examination, he has a positive quadriceps active test, Which knee ligament in most likely injured in this patient?

Quadriceps Active Test

 A) Anterior cruciate ligament (ACL)
B) Posterior cruciate ligament (PCL)
C) Lateral collateral ligament (LCL)
D) Medial collateral ligament (MCL)
E) Posterolateral corner complex (PLC)

Best answer: B

The PCL extends from the medial femoral condyle to the tibial sulcus Overall the most common mechanism of PCL injury is a direct blow to the proximal aspect of the tibia such as dash board injury. The most common mechanism of PCL injury in athletes is a fall onto the flexed knee with the foot in plantar flexion, which places posterior forces on the tibia and leads to rupture of the PCL.Treatment of isolated PCL injury is mainly focused on protected weight bearing, followed with quadriceps rehabilitation

Janousek AT, Jones DG, Clatworthy M, Higgins LD, Fu FH. Posterior cruciate ligament injuries of the knee joint. Sports Med 1999; 28:429-441

Author : Firas Arnaout

 

5.  The posterior approach to the acetabulum and hip provides good exposure for fixing for hip fractures and hip arthroplasty. 

Where is the sciatic nerve likely to be found?

A) Under the piriformis muscle
B) Above the piriformis muscle
C) Under the quadratus femoris
D) Underneath the gluteus minimus
E) Exits through the obturator foramen

Best answer:  A

The sciatic nerve supplies the muscles at the back of the thigh to extend the hip and flex the knee. It exits through the greater sciatic notch and appears in the gluteal region below the lower border of the piriformis muscle in the vast majority of cases. In the surface anatomy, it is located in the lower medial quadrant of gluteal region; it is accompanied by the inferior gluteal artery.

The superior gluteal nerve and artery leave the pelvic above the piriformis and underneath the gluteus minimus. The medial circumflex femoral artery passes underneath the quadratus femoris.

Netter FH: Atlas of Human Anatomy. West Caldwell, NJ,
CIBA-Geigy, 1989

Author :Firas Arnaout

 

4.  A  69 years old man presented with ipsilateral hip and knee pain. On examination, he has painful and restricted movement of the hip, but knee movements were complete and painless.Radiographes of the hip and knee show severe degenerative arthritis of the hip and mild arthritis of the knee. 

Which nerve is responsible for this patient’s referred pain from hip to knee?

 A) The femoral nerve
B) The sciatic nerve
C) The lateral femoral cutaneous nerve
D) The saphenous nerve
E) The obturator nerve 

Best answer:  E

The obturator nerve come from L2, L3 and L4 nerve roots and enters the thigh through the obturator canal before dividing into anterior and posterior branches.it is at risk during anteromedial (Ludloff) approach to the hip.
It provides sensation to medial aspect of thigh and to both hip and knee joints, therefore some of hip pain could radiate to the knee.

Author :Firas Arnaout

 

3.  A 28 years old man was involved in a motorbike road traffic accident sustaining head injury resulting in a coma and hip fracture. 

Indomethacin is indicated here to prevent which complication?

A) Non union
B) Infection
C) Vascular compromise
D) Pressure ulcers
E) Heterotopic ossification 

Best answer:  E

Heterotopic ossification is formation of bone in the soft tissues, may occur spontaneously or following trauma .It is usually not painful, but presents with loss of movements. Prolonged ventilation time, brain injury, spinal cord injury, burns, and amputation thru the zone of injury in a patient injured in a blast are all literature proven risk factors for development of heterotopic ossification. Prophylaxis is with the use of Bisphosphonates and Indomethacin and raditherpay.Surgical excision could be performed if there is sever loss of movements.

 Pape HC, Lehmann U, van Griensven M, Gänsslen A, von Glinski S, Krettek C. Heterotopic ossifications in patients after severe blunt trauma with and without head trauma: incidence and patterns of distribution. J Orthop Trauma. 2001 May; 15(4):229-37

Author :Firas Arnaout

 

2.  25 years old rugby player sustained posterior hip dislocation when several players landed on his back with the hip flexed to 90 degrees, resulting in posterior hip dislocation. 

Hip Dislocation – Core EM

What is the most common complication of hip dislocation?

A) Posttraumatic arthritis
B) Avascular necrosis
C) Sciatic nerve injury
D) Recurrent dislocation
E) Femoral artery occlusion

Best answer: B

 

All the above are recognised complication of hip dislocation. Arthritis incidence is up to 20% and is dependent on the severity of dislocation and associated fractures.

Sciatic nerve injury is up to 20% and increases with longer time to reduction.

AVN incidence is up to 40% and recurrent dislocation is 2%

 Author :Firas Arnaout


1.  A 14 years old boy attended the orthopaedic clinic with a swollen painful knee and inability to weight bear. 

What is the most common cause of recurrent haemoarthrosis ?

A) Minor trauma
B) Septic Arthritis
C) Haemophilic arthropathy
D) Osteoarthritis
E) Inflammatory arthritis

Best answer: C

Minor trauma should not cause recurrent haemoarthropathety unless it is associated with a bleeding disorder. Septic and inflammatory arthritis very rarely cause haemoarthrosis.Osteoarthritis is rare in the young patient.

Causes Haemophilic arthropathy include: haemophilia and Von Willebrand disease. They are X linked affecting boys only. Sever cases could require factor VIII transfusion 

 http://www.orthobullets.com/basic-science/9051/hemophilic-arthropathy

 Author :Firas Arnaout

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