Knee and sport Flashcards

Question 1

Q

ACL: Mechanism of injury

Answer

A

non-contact pivoting injury

Question 2

Q

ACL: Common associated injury in ACL tear

Answer

A

Lateral meniscus injured in 54%

Question 3

Q

ACL: Concomitant pathology in Chronic ACL tear (3)

Answer

A

OCD
Complex meniscal tear
Arthritis (controversial)

Question 4

Q

ACL Tear:

Gender predisposition
Reason / details

Answer

A

F:M = 4.5:1
a. landing biomechanics and neuromuscular activation patterns (quadriceps dominant) play the biggest role

notes:
- females get ACL injury at younger age
- females get more ACL injuries on the supporting leg / males get more ACL injuries on the kicking leg

Question 5

Q

ACL: Function
i. _______% responsible for prevention Ant. Translation of Tibia

ii. Secondary restraint to what other tibial motion

Answer

A

i. 85%

ii. Tibial rotation and varus/valgus rotation

Question 6

Q

ACL Anatomy
i. Length

ii. Width

Answer

A

i. 32mm

ii. 7-12mm

Question 7

Q

ACL: Anatomy
Anteromedial bundle is:

i. more or less isometric?
ii. Tight throughout ROM but tightest in ____________

iii. Primarily stops _________
and is tested best by ________ test

Answer

A

i. More
ii. Flexion
iii. Primarily stops ANT. TIBIAL TRANSLATION and is tested by ANTERIOR DRAW TEST

Question 8

Q

ACL: Anatomy

Posterolateral bundle is:

i. more OR less isometric
ii. Tightest in _________ and slack in ___________
iii. Primarily responsible for ___________ stability (test:

Answer

A

i. LESS (ie. greater length changes with ROM)
ii. Tightest in EXTENSION and slack in MID-FLEXION
iii. primarily responsible for ROTATIONAL STABILITY (test: PIVOT SHIFT)

Question 9

Q

ACL Anatomy

i. Femoral attachment - anterior border ?
ii. Femoral attachment: Bony landmark separating AM/PL bundle
iii. The tibial attachment is anterior tibia between the __(a)___ just medial to anterior horn of __(b)___ meniscus

Answer

A

i. Lateral intercondylar ridge
ii. Bifurcate ridge

iii.
a) INTERCONDYLAR EMINENCES

b) LATERAL

Question 10

Q

ACL Anatomy:
i. Blood supply

ii. Innervation
iii. Composition = 90% Type (a) and 10% Type (b) collagen
iv. Strength: ____ N (anterior)

Answer

A

i. middle geniculate artery
ii. posterior articular nerve (branch of tibial)
iii. a=type 1 ; b=type 3
iv. 2200

Question 11

Q

ACL Clinical:
i. Most sensitive test (physical exam) for ACL rupture ?

ii. Grading test
(a) A = ____ endpoint / B= ____ endpoint
(b) Grade 1: _____mm translation / Grade 2 ____mm / Grade 3 _____mm

iii. False test may occur with ________

Answer

A

i. Lachman’s
ii. (a) A= firm ; B= no
(b) Grd 1 = 3-5mm / Grd 2 =5-10mm / Grd 3 = >10mm
iii. PCL tear

Question 12

Q

ACL Clinical
i. What is pivot shift ?

ii. Must have an intact ______ for this to work

Answer

A

i. Knee moved from ext to flex and joint reduces/”clunks” at 20-30° of flexion
ii. MCL

Question 13

Q

Imaging ACL: Segond fracture
i. What is a Segond fracture

ii. Segond represents a bony avulsion of the _____
iii. Assoc. with ACL in ____% of cases

Answer

A

i. Avulsion of prox lateral tibia
ii. Anterolateral ligament
iii. 75-100%

Question 14

Q

Imaging ACL: XRay

i. Apart from Segond # what other XR sign is assoc with ACL tear ?
ii. What causes this sign?

Answer

A

i. Deep sulcus (terminalis) sign
OR “sulcus sign”

ii. Depression on the lateral femoral condyle at the terminal sulcus
(Represents OCD fracture - OCD>1.5cm reliably associated with ACL injury)

Question 15

Q

Imaging ACL: MRI

i. sagittal view findings of ACL
(a) ___________

(b) ___________
(c) ___________

Answer

A

i.
(a) discontinuity of fibres on T2

(b) abnormal orientation (flat compared to blumensaat line /intercondylar roof)
* * can occur in chronic cases - ACL stick to PCL

(c) no ACL seen

Question 16

Q

imaging ACL: mri
i. bone bruising seen in > __%

ii. most common locations
(a) , (b) , (c)

Answer

A

i. >50%

II.
(a) middle third of lfc (sulcus terminalis)

(b) Post. third of LTP
(c) Subchondral change persisting years in some cases

Question 17

Q

imaging : mri
finding on coronal view:
i.what is the “empty notch sign”?

Answer

A

Sign of ACL rupture -> caused by fluid against the lateral wall

Question 18

Q

Treatment ACL: Non-op

i. non-op treatment: indications
ii. factors linked to cartilage/meniscal damage in ACL deficiency (3)

Answer

A

i. low demand and decreased laxity

ii.
(1) Loss meniscal integrity

(2) Frequency of “buckling” episodes/instability
(3) Level I/II activity (jumping, cutting, side-to-side sport, manual labour)

Question 19

Q

Treatment ACL: Operative

i. indications (4)

Answer

A

i.
- younger, more active

children (strongly consider operative as activity limitation is not realistic)
older active patients (age >40 is not a contraindication if high demand athlete)
prior ACL reconstruction failure

Question 20

Q

ACL: Treating assoc. injury

i. MCL injury: How to Rx?
ii. Meniscal tear: How to Rx?
iii. posterolateral corner injury: How to Rx?

Answer

A

i. allow MCL to heal (varus/valgus stability) and then perform ACL

* Note: varus/valgus instability can jeopardize graft*

ii. meniscal repair at the same time as ACL
* ** Note: increased meniscal healing rate when repaired at the same time as ACL

iii. recon PLC at the same time as ACL or as 1st stage of 2 stage recon

Question 21

Q

ACL: Return to sport

i. What determines time to return to sport ? (3)

Answer

A

1) Psychological
2) Functional
3) Demographics

Question 22

Q

ACL Repair: what is BEAR procedure ?

Answer

A

Arthroscopic Bridge-Enhanced ACL Repair (BEAR) (note: trial with a bridging scaffold is ongoing)

** addit: repair traditionally high failure rate

Question 23

Q

ACL Recon Technique: Femoral tunnel

i. Correct placement
(a) Sagittal placement

(b) Coronal placement

Answer

A

i(a). 1-2 mm rim of bone between the tunnel and posterior cortex of the femur

i(b). Lateral wall @ 9-10 o’clock position to create a more horizontal graft

Question 24

Q

ACL Recon Technique: Tibial tunnel

i. Correct placement
(a) Sagittal placement

(b) Coronal placement

Answer

A

i (a).
center of tunnel should be 10-11mm in front of the anterior border of PCL insertion

i (b). tunnel trajectory of < 75° from horizontal

*** obtain by moving tibial starting point halfway between tibial tubercle and a posterior medial edge of the tibia.

Question 25

Q

ACL Recon Technique: Graft Placement

i. Graft preconditioning can reduce ____ by up to 50%
ii. Graft tension
iii. position of knee during graft tension ?

Answer

A

i. stress relaxation up to 50%

ii. controversial
- 20N or 40N had no clinical outcome effects in a level 1 study
- DONT overtension

iii. 20-30° of flexion

Question 26

Q

Principles for revision ACL

i. technique (4)
ii. post-op (1)

Answer

A

i. (1) high-strength grafts (quads , hamstring, allograft)
(2) use dual fixation
(3) bone grafting (tunnel dilation, poor bone stock, staged)
(4) re-harvesting BTB is contraindicated

ii. conservative rehab

Question 27

Q

ACL Technique: Graft Selection

i. Bone-Tendon-Bone
a) Pros (4
(b) Cons (1)
(c) Complications (2)

Answer

A

ia. (1) longest data/Hx “gold-standard”
(2) bone-to-bone healing
(3) can rigidly fix joint line (screws)
(4) Strong @ 2600N

ib. (1) High incidence ant knee pain (up to 10-30%)

ic. (1) patella # (during rehab)
(2) rerupture (assoc w <20yo & graft size <8mm)

Question 28

Q

ACL Technique: Graft Selection

i. Quadruple hamstring autograft
a) Pros (4
(b) Cons (3)
(c) Complications (2)

Answer

A

ia. (1) less perioop pain; (2) less ant knee pain; (3) small incision (4) load to failure 4000N

ib.
(1) fixation strength may be < than BTB; (2) decreased peak flexion strength at 3 years vs. BTB; (3) concern re: hamstring weakness in female athletes –> increased risk of re-rupture

ic. (1) “windshield wiper” effect (ie. suspensory fix. causes tunnel abrasion & expansion with rpt knee ROM)
(2) residual hamstring weakness

Question 29

Q

ACL Allograft
i. pros

ii. cons

iii. processing
(a) Problem with processing allograft with supercritical CO2 and/or radition?

(b) Deep freezing and 4% Chlorhex cause __(1)__ but dont effect __(2)___

Answer

A

i. revision / no donor site morbidity
ii. (1) disease transmission (HIV <1.1 million / Hep even less); (2) slow integration; (3) re-rupture 4.3X higher in pt <20
iiia. both pre-Rx cause decreased strucutral and mech properties
iiib. (1) cell death; (2) strucutral and mech properties

Question 30

Q

ACL: Paediatric Considerations

Treatment in open physis

i. Non-op
(a) indications

ii. Operative
(a) indications

Answer

A

ia. (1) compliant, low demand pt with no additional intra-articular pathologies
(2) partial ACL tear (60% of adolescents) with near normal Lachman and pivot shift

iia. (1) complete tear

Question 31

Q

ACL: Paediatric Considerations

i. Technique:
(a) intra-articular (3)

(b) Combined intra-/Extra- articular - what age ?
(c) Adult type - what age ?

Answer

A

ia. (1) Physis sparing (intra-epiphyseal);
(2) Transphyseal (M<13-16; F<12-14);
(3) Partial transphyseal

ib. M<12; F <11
ic. M>16 ; F >14

Question 32

Q

ACL: Paediatric Considerations

i. (a) what graft? (b) why?

Answer

A

i. (a) soft tissue; (b) rarely cause growth arrest

ii.

Question 33

Q

ACL: Paediatric Considerations

i. Factors found to increase physeal injury include:

a) Tunnel diameter >____mm
b) ________ tunnel position
c) with OR without interference screw ?
d) ________ reaming
e) Others (3)

Answer

A

a) >12mm
(note: 8mm=3% of physis cross-sectional area / 12mm >7-9%)

b) Oblique
c) with = higher risk
d) high speed
e) (1) suturing close to tib tub; (2) lateral extra-art tenodesis; (3) dissection near ring of LaCroix

Question 34

Q

ACL Rehabilitation

i. immediate
a) Ice Y/N ?
b) Weight-bearing - Y/N?
c) Early passive full extension esp in what group?

Answer

A

a) Yes
b) Yes. Evidence for reductino in PFJ pain
c) Especially in assoc MCL injury OR patella dislocation

Question 35

Q

ACL Rehabilitation

i. Early
a) Eccentric strength in first __(1)__ weeks has shown __(2)__

b) ________ hamstrings/quads contraction
c) active knee motion ____ to _____ degrees
d) emphasize ______ chain exercise
e) Avoid ? (2)

Answer

A

ia. (1) 3 weeks; (2) incr quads volume and strength
ib. Isometric
ic. 35-90 degrees
id. closed chain (exs with foot planted)

ie. (1) Isokinetic quad strength (15-30°)
(2) open chain quad strength

Question 36

Q

ACL Surgery: Complications

Tunnel Malposition
i. Causes failure in ____%

ii. Femoral
(a) coronal
(b) Sagital

iii. Tibial
(a) coronal
(b) Sagital

Answer

A

i. 70% (most common cause of failure)
iia. vertical femoral tunnel placement = continued rotational instab

iib.
- ant placement = knee too tight in flexion and loose in extension; posterior misplacement (opposite previous)

iiia. ant placement = knee tight in flex + impingement in ext;
iiib. post. placement = ACL will impinge with the PCL

Question 37

Q

ACL Surgery: Complications

Other causes of failure (14)

Answer

A

inadequate graft fixation (graft-screw divergence >30 degrees)
missed diagnosis other injuries
overaggressive rehab
Infection
- coag -ve Staph most common; S. epi > s. aureus
-often can retain graft with multiple I&Ds and antibiotics (6 weeks minimum)
Loss of motion & arthrofibrosis (preoperative prevention; regain full ROM during pre-hab; higher risk in acute phase; Rx: <12/52= Rx with aggressive PT and serial splinting / > 12/52 Rx with lysis of adhesions/MUA
Infrapatellar contracture syndrome (decreased patellar translation on exam)
PT Rupture
*. RSD/CRPS
Patella fracture (most fx occur 8-12/52 postop)
9 Hardware failure
10 Tunnel osteolysis (Rx with observation)
Late arthritis (related to meniscal integrity)
Local nerve irritation (saph.nerve)
13 Cyclops lesion (fibroproliferative tissue blocks ext; “click” heard at terminal extension)

Question 38

Q

Hip Labral Tear

definition
Epidemiology
a) incidence highest in patients with ___________
Demographics
Location of tear most commonly _________

Answer

A

Definition: Traumatic tear of the acetabular labrum that may lead to pain, intra-articular snapping hip
Epidemiology
a) incidence highest in patients with acetabular dysplasia
Demographics
◾seen in all age groups
◾patients commonly active females
Anterosuperior labrum most common location

Question 39

Q

Hip Labral Tear

Pathophysiology

etiology
i. )
ii. )
iii. )
iv. )
v. )

Answer

A

Pathophysiology

etiology
i. ) femoroacetabular impingement

ii.) hip dysplasia
◾ floppy labrum more susceptible to tearing

iii.) trauma
◾ hip disloc/sublux are a common cause

iv.) capsular laxity
◾incr. translational forces across labrum due to joint hypermobility

v.) joint degeneration
◾causes acetabular edge loading

Question 40

Q

Hip Labral Tear

Anatomy

Structure
Has 2 parts:
i. _________
◦ composed of __________
ii. ________
◦ composed of __________
Vascularity
Innervation

Answer

A

Structure : horse-shoe shaped structure continuous with transverse acetabular ligament
Has 2 parts:
i. articular
◦ fibrocartilage
ii. capsular
◦ dense connective tissue
Vascularity:
◦ capsule and synovium at acetabular margin
Innervation
◦branch of nerve to the quadratus femoris
◦obturator nerve

Question 41

Q

Hip Labral Tear

Presentations

Symptoms
Physical examination
a. ) provacation test for anterior labral tear?
b. )provacation test for posterior labral tear?

Answer

A

Symptoms
◦mechanical hip pain and snapping
◦may have vague groin pain
◦may be associated with a sensation of locking
Physical exam

a) provocative tests : anterior labral tear
◾pain if hip is brought from a fully flexed, externally rotated, and abducted position to a position of extension, internal rotation, and adduction

b.) provocative tests : posterior labral tear
◾pain if hip is brought from a flexed, adducted, and internally rotated position to one of abduction, external rotation, and extension.

Question 42

Q

Hip Labral Tear

Imaging

Gold standard
Radiographs

Answer

A

Imaging

Gold Standard = MRI arthrogram
◾92% sensitive for labral tears
◾may be combined with intra-articular injections of lidocaine and steroid for diagnostic and therapeutic purposes
Radiographs
◾ useful to exclude other types of hip pathology
◾ may show: ◦ hip dysplasia ◦ arthritis ◦ acetabular cysts

Question 43

Q

Hip Labral Tear

Treatment : Non-op

details
Indications
Outcomes

Answer

A

Rest, NSAIDS, physical therapy, steroid injections
Indications
◾initial treatment of choice for all patients with labral tears
Outcomes
◾no long-term follow-up data on conservative management

Question 44

Q

Hip Labral Tear

Treatment : Operative

Arthroscopic labral debridement
a. Indications
b. Technique
c. Post-operative care

d. Outcomes
◾__to___% experience short-term relief of symptoms following arthroscopic debridement

Arthroscopic labral repair
a. indications
b. outcomes

Answer

A

Operative

Arthroscopic labral debridement

a.) Indications
◾symptoms that have failed to improve with nonoperative modalities
◾labral tear not amenable to repair

b.) Technique
◾remove any unstable portions of the labrum and associated synovitis
◾underlying hip pathology (e.g. FAI) should also be addressed at time of surgery

c.) Post-operative care
◾limited weight-bearing x4 weeks
◾flexion and abduction are limited for 4 to 6 weeks

d.) Outcomes
◾70-85% experience short-term relief of symptoms following arthroscopic debridement
◾long-term follow-up data not available

arthroscopic labral repair
a.) indications
◾symptoms and failed nonoperative modalities
◾full-thickness tears at the labral-chondral junction

b.) outcomes
◾unknown at this time

Question 45

Q

Hip Labral Tear

An active 23-year-old man has right groin pain that increases with sports activity. Examination reveals decreased internal rotation of the affected hip. He has a positive impingement test and radiographs reveal no crossover sign. An MRI scan is most likely to reveal which of the following?

Abnormal alpha angle and a chondrolabral tear
Acetabular retroversion
Heterotopic ossification
Ankylosing spondylitis
Coxa varum

Answer

A

A. Abnormal alpha angle and a chondrolabral tear

Explaination:
Young patients with hip pain and a positive impingement test are likely to have femoroacetabular impingement. The triad seen in these patients is a reduced concavity at the femoral head-neck junction, which leads to an increase in alpha angle and a chondrolabral tear. MR-arthrogram is the cross-sectional imaging modality of choice. These patients usually have reduced internal rotation and a positive impingement sign. The other findings, though possible, are not the most likely scenario in this young and active patient.

Question 46

Q

Hip Labral Tear

Which of the following statements best describes labral tears in the hip?

They are unrelated to degenerative joint disease.
They lead to increased movement of the femur relative to the acetabulum.
They usually result from lesions of the ligamentum teres.
They only occur with abnormal bone morphology.
They commonly occur in the posteroinferior quadrant of the hip.

Answer

A

A. They lead to increased movement of the femur relative to the acetabulum.

Explaination:
Labral and chondral lesions are observed within the anterosuperior quadrant of the acetabulum. Tearing of the labrum markedly reduces resistance to joint motion, leading to instability. The most common associated lesions are chondral injuries. They can occur with or without abnormal bone morphology. The etiology for labral tears can be from traumatic and degenerative causes, structural abnormalities from femoroacetabular impingement, developmental abnormalities, and hip instability

Question 47

Q

Femoroacetabular Impingement

A common cause of :
◦ early onset hip dysfunction
◦ secondary osteoarthritis

Epidemiology (3 Types)

Answer

A

Epidemiology

a.) Cam impingement  
◾refers to FEMORAL disorder is usually in young athletic males and includes 
◾decreased head-to-neck ratio
◾aspherical femoral head
◾decreased femoral offset
◾femoral neck retroversion 
◾can be due to previous SCFE deformity

b.) Pincer impingement  
◾refers to ACETABULAR based disorder usually in active middle-aged women and includes  
◾anterosuperior acetabular rim overhang
◾acetabular retroversion
◾acetabular protrusio
◾coxa profunda

c.) Combined Cam/Pincer impingement
◾can include both patient populations
◾refers to combinations of above (up to 80%)

Question 48

Q

Femoroacetabular Impingement

Mechanism
Pathoanatomy (ie what is cause of pain/impingement)
Associated injuries (3)

Answer

A

Mechanism
◦ result of impingement of the femoral neck against anterior edge of acetabulum
Pathoanatomy
◾ proximal femur abuts acetabulum with range of motion, especially in flexion:
◦ occurs if femoral head/neck bone is too broad in
Cam impingement
◦ occurs if acetabular bone/labrum overhang is too broad in Pincer impingement
Associated injuries
◾ labral degeneration and tears
◾ cartilage damage and flap tears
◾ secondary hip osteoarthritis

Question 49

Q

Femoroacetabular Impingement

Presentation

Symptoms
Examination findings

Answer

A

Symptoms
◦activity related groin or hip pain, exacerbated by hip flexion
◦difficulty sitting
◦mechanical hip symptoms
◦can present with gluteal or trochanteric pain (due to aberrant gait mechanics)
Exam
◦limited hip flexion (<90 degrees), especially with internal rotation (<5 degrees)
◦anterior impingement test (flexion, adduction, internal rotation) elicits pain
◦externally rotated extremity (can be due to post-SCFE deformity)

Question 50

Q

Femoroacetabular Impingement

Imaging

Radiographs
Characteristic findings on radiographs

Answer

A

Radiographs
◾ Radiographic views
◦ false profile view:
- to assess anterior coverage of the femoral head
- standing position at an angle of 65° between the pelvis and the film (end-on to femoral head)
Characteristic findings
i.) Asphericity and contour of femoral head and neck (‘pistol-grip’ deformity)
◾ indicates Cam impingement

ii.) Examine for acetabular protrusio, retroversion, and coxa profunda
◾Crossover sign
◦indicates acetabular retroversion in Pincer impingement

Question 51

Q

Femoroacetabular Impingement

Imaging : Measurements

What is alpha angle ?
What is normal alpha angle ?
What is the head-neck offset ratio ?
What is the head-neck ratio ?

Answer

A

Alpha angle:

i.) Method = measured frog-leg lateral radiograph
◾ First line is drawn connecting the center of the femoral head and the center of the femoral neck
◾Second line is drawn from the center of the femoral head to the point on the anterolateral head-neck junction where prominence begins
◾The intersection of these two lines forms the alpha angle

Values of >42° are suggestive of a head-neck offset deformity
Head-neck offset ratio

i.) Method
◾Measured from lateral radiographs
◾Line #1 is drawn through the center of the long axis of the femoral neck
◾Line #2 is drawn parallel to line 1 through the anteriormost aspect of the femoral neck
◾Line #3 is drawn parallel to line 2 through the anteriormost aspect of the femoral head
◾The head-neck offset ratio is calculated by measuring the distance between lines 2 and 3, and dividing by the diameter of the femoral head

Normal values = If the ratio is <0.17, a cam deformity is likely present

Question 52

Q

Femoroacetabular Impingement

Treatment : Nonoperative

Details
Indications

Answer

A

observation
Indications
◾minimally symptomatic patient
◾no mechanical symptoms

Question 53

Q

Femoroacetabular Impingement

Treatment : Operative

Details (4 surgical treatment options)
Indications / Contraindications
Outcomes

Answer

A

Arthroscopic hip surgery

a.) Indications
◾symptomatic patient
◾mechanical symptoms

b.) Outcomes
◾recent literature supports arthroscopy shows equivalent results to open hip surgery

Open surgical hip dislocation

a.) Indications
◾gold standard for management of FAI for patients with clinical signs and structural evidence of impingement and…
◾preserved articular cartilage, correctable deformity, reasonable expectations

b.) Contraindications
◾age >55, morbid obesity, advanced joint disease

Periacetabular osteotomy

a.) Indications
◾structural deformity of acetabulum with poor coverage of femoral head

b.) technique ◾osteotomy and fixation

THR
a.) Indications
◾age >60 years and end-stage hip degeneration

Question 54

Q

Femoroacetabular Impingement

Operative Technique : Arthroscopic hip surgery

Approach
Technique

Answer

A

Approach
◾arthroscopic approach to the hip
Technique
◾trim femoral head/neck in Cam impingement
◾acetabular rim labral debridement vs repair
- isolated labral debridement will not solve problem without treatment of underlying pathology

Question 55

Q

Femoroacetabular Impingement

Operative Technique : Open surgical hip dislocation

Approach
Technique

Answer

A

Approach
◾anterior (Smith-Peterson) approach
◦ best for isolated femoral head/neck pathology due to limited exposure, although it is possible that acetabular side could be treated
◦ acetabular treatment involves take down of rectus femoris reflected head
◦ femoral osteotomy and fixation
Technique
◾uses a “trochanteric flip” for safe access to proximal femur and acetabulum
◦ provides best visualization for hip surgery
◦ preserves all external rotators and blood supply to femoral head (medial circumflex femoral artery)
nb: no increase in AVN risk
◦ provides wide exposure of femoral head and acetabulum

Question 56

Q

Femoroacetabular Impingement

Complications (3)

Answer

A

Complications

Femoral neck fracture
◦ at risk during open or arthroscopic debridement of Cam lesions
◦ risk is minimized by limiting depth of femoral head-neck osteochondroplasty to <30% of femoral neck diameter
Heterotopic Ossification
Persistent CAM and pincer lesions following arthroscopic treatment

Question 57

Q

Trochanteric Bursitis

Epidemiology

demographics
risk factors

Pathophysiology

pathoanatomy
Trochanteric bursa is (a) to the hip abductor muscles and (b) to the iliotibial band

Answer

A

demographics
◾often occurs in female runners
risk factors
◾Is associated with training on banked surfaces
pathoanatomy
◾repetitive trauma caused by iliotibial band tracking over trochanteric bursa
◾can irritate the bursa causing inflammation
a) superficial ; b) deep

Question 58

Q

Trochanteric Bursitis

Presentation

Symptoms
Physical exam
Imaging : Radiographs
Imaging: MRI

Answer

A

Presentation
1. Symptoms
◦lateral sided hip pain, although hip joint is not involved
2. Physical exam
◦pain with palpation over greater trochanter
3. Imaging : Radiographs ◦will be unremarkable
4. Imaging :MRI
◦will show increased signal in bursa due to inflammation on T2 sequence

Question 59

Q

Trochanteric Bursitis

Answer

A

Treatment

Nonoperative ◦NSAIDS, stretching, PT including modalities, corticosteroid injections
◾indications = first line treatment is always conservative
Operative ◦open vs arthroscopic trochanteric bursectomy
◾indications ◾is done only after conservative measures fail

Question 60

Q

Hip Arthroscopy

indications (10)

contraindications (5)

Answer

A

Indications  
◦FAI 
◦labral tears
◦AVN (diagnosis and staging)
◦loose bodies
◦synovial disease
◦chondral injuries
◦ligamentum teres injuries
◦snapping hip
◦mechanical symptoms
◦impinging osteophytes

•Contraindications ◦advanced DJD
◦hip ankylosis
◦joint contracture
◦severe osteoporotic bone
◦significant protrusio acetabuli

Question 61

Q

Hip Arthroscopy: Setup

Position ?
Joint distension
Requires traction
◾~__lbs of traction

4 _______ scope placed first. _______ portal placed second ◾then placed under fluoroscopic guidance with the hip flexed and in internal rotation ◦_______ portal placed last

Answer

A

Position ◦ supine or in lateral decubitus position
Joint distension ◦can load joint with saline to distend joint ◾typically done under flouroscopic guidance
requires traction in line with the femoral neck ◾well padded perineal post
◾~50 pounds of traction
ANTEROLATERAL scope placed first (arthroscope insertion over guidewire) ANTERIOR portal placed second ◾then placed under fluoroscopic guidance with the hip flexed and in internal rotation; POSTERIOR portal placed last

Question 62

Q

Hip Arthroscopy

anterolateral portal

function
location

Answer

A

function ◾primary viewing portal ◾anterolateral hip joint access
location and technique ◾located 2 cm anterior and 2 cm superior to anterosuperior border of greater trochanter ◾typically established first under fluoroscopic guidance

Question 63

Q

Hip Arthroscopy

Posterolateral portal

function
location

Answer

A

◦function ◾posterior hip joint access

◦location and technique ◾located 2 cm posterior to the tip of the greater trochanter

Question 64

Q

Hip Arthroscopy

Anterior portal

function
location

Answer

A

function ◾anterior hip joint access
location and technique ◾ located at intersection between ◾superior ridge of greater trochanter
◾ASIS ◾flexion and internal rotation of hip loosens capsule and assists scope insertion

Answer 65

A

myotendinous junction ◾is the most common site of rupture ◾often occurs during sprinting
i. seen in skeletally immature; ii. seen in water skiers
Mechanism ◦occurs as a result of hip flexion and knee extension
Pathophysiology ◦satellite cell plays a role in muscle healing following muscle injury

Answer 66

A

Relevant Anatomy
1. “Hamstring” muscles
i. semimembranosus topic ◾most lateral attachment
ii. semitendinosus topic ◾semitendinosus and biceps femoris (long head) attach medial to semimembranosus
iii. biceps femoris
◾long head topic ◦ attaches medial to semimembranosus
◾short head topic ◦ origin from linea aspera
2. Common characteristics of hamstring muscles include ◦originate on ischial tuberosity
◦innervated by sciatic (tibial) nerve
◦blood supply from inferior gluteal artery and profunda femoral artery
◦cross and act upon 2 joints: the hip and knee (except short head of biceps femoris)

Answer 67

A

Physical exam ◦ecchymosis in posterior thigh
◦may have palpable mass in middle 1/3 of posterior thigh (myotendinous rupture)
◦normal hamstring/quadricep ratio is 65%
◦stiff legged gait (avoiding knee and hip flexion)

2 . avulsion off ischial tuberosity

avulsion off ischial tuberosity

Answer 68

A

Treatment :Nonoperative
1. rest, ice, NSAIDS, PWB for 4/52 followed by stretching and strengthening

◾most hamstring injuries
◾single tendon, retraction ≤1-2cm ◾rupture at myotendinous junction
Return to play ◾only when strength is 90% of contralateral side to avoid further injury

Answer 69

A

indications:
◾proximal avulsion ruptures ◾partial avulsion that has failed nonop rx for 6/12
◾at least 2 tendons but > 2cm retraction in young, active patients

2. surgical technique  
◾TV incision at gluteal crease
◾protect sciatic nerve
◾mobilization of the ruptured tendons
◾repair to the ischial tuberosity with the use of suture anchors

results
◾easier to mobilize acute ruptures than chronic ruptures
◾repair of acute ruptures has less sciatic nerve scarring (nb: chronic ruptures may require sciatic neurolysis)

Answer 70

A

Complications

Weak in knee flex; hip ext
Hamstring syndrome= posterior buttock and ischial tuberosity pain
Treatment ◾surgical release and sciatic nerve decompression
Sciatic nerve scarring and sciatic neuralgia

Answer 71

A

Introduction
1. An injury commonly seen in athletes ◦occurs as a result of direct trauma
(common in contact sports)

Answer 72

A

Symptoms
◦pain at anterior thigh
Physical exam ◦tenderness at ant thigh
◦ltd active knee flex due to pain
◦possible knee effusion
◦perform SLR to ensure ext mech intact
Femoral nerve (lateral, intermediate, and medial cutaneous nerves) during evaluation for compartment syndrome

Answer 73

A

XRay
◦imaging not necessary if mild contusion and ext mech intact
◦plain radiograph to evaluate for myositis ossificans in chronic injuries
MRI ◦ highest sens/spec disorders of the quadriceps
◦MRI helpful in moderate to severe contusions or if quadriceps tendon competency in doubt

Answer 74

A

Sustained at any level of play or competition, myositis ossificans is the formation of bone tissue inside muscle tissue after a traumatic injury to the area.

Answer 75

A

Treatment : Nonoperative

1a) Immobilize in 120 degrees of knee flexion for 24 hrs followed by therapy
◾cold therapy
◾ACE bandage or hinged knee brace
1b) ◾begin active pain-free quads stretching several times a day thereafter ◾WBAT (crutches often needed initially)
◾close monitoring for compartment syndrome

indications: ◾acute injuries
ATIIRB (e.g. Losartan)
a) indications: ◾increase muscle regeneration after contusion ◾decrease fibrosis
b) mechanism: ◾blockade of IGF ◾reduces apoptotic cascade of muscle

Answer 76

A

Operative: thigh fasciotomies
◾indications
-> compartment syndrome

Answer 77

A

Compartment syndrome ◦usually rupture of deep perforating branches of the vastus intermedius
Myositits ossificans ◦incidence of 5-9% rate with quadriceps contusion

Answer 78

A

Epidemiology:◦higher risk in ACL deficient knees
MEDIAL tears = more common than lateral tear EXCEPT in the setting of an acute ACL tear where lateral tears are more common
POSTERIOR horn of MEDIAL meniscus

Answer 79

A

Descriptive classification

1) Location ◾red zone (outer third, vascularized) ◾red-white zone (middle third) ◾white zone (inner third, avascular)
2. Size
3. pattern
i) vertical/longitudinal ◦ common, esp. with ACL tears ◦ repair when peripheral
ii) bucket handle ◦ vertical tear which may displace into the notch
iii) oblique/flap/parrot beak ◦ may cause locking
iv) radial
v) horizontal ◦ more common in older population ◦ may be assoc with meniscal cysts
vi) complex

Answer 80

A

Apleys compression
Thessaly test
McMurray

Answer 81

A

Thessaly test
◾standing at 20 degrees of knee flexion on the affected limb, the patient twists with knee external and internal rotation with positive test being discomfort or clicking.
Apley compression ◾perform prone

Answer 82

A

McMurray’s test
◾flex the knee and place a hand on medial side of knee, externally rotate the leg and bring the knee into extension.
◾a palpable pop / click + pain is a positive test and can correlate with a medial meniscus tear.

Answer 83

A

Normal vs. Meniscal calcifications
MRI
a) MRI is most sens. but also has a high false positive rate
b) ◾MRI grade III signal is indicative of a tear ◾linear high signal that extends to either superior or inferior surface of the meniscus
Parameniscal cyst
bucket handle tears
bucket handle tears

Answer 84

A

Saph neuropathy (7%)
Arthrofibrosis (6%)
Sterile effusion (2%)
Peroneal neuropathy (1%)
Superficial infection (1%)
Deep infection (1%)

Answer 85

A

Non-operative ◦rest, NSAIDS, rehabilitation ◾indicated as first line of treatment for degenerative tears

Answer 86

A

indications: ◾ tears not amenable to repair (complex, degen, radial tear)
◾repair failure >2 times
Outcomes:
◾>80% satisfactory function at minimum follow-up
◾50% have Fairbanks radiographic changes (osteophytes, flattening, joint space narrowing)

Answer 87

A

predictors of success
a) age <40yo
b) normal alignment
c) minimal or no arthritis
d) single tear

Answer 88

A

indications
a. ) peripheral in the red-red zone (vascularized region)
b. ) rim width= distance from the tear to the periph meniscocapsular junction (blood supply) ** rim width correlates with the ability of a meniscal repair to heal (lower rim width has better blood supply)
c. ) vertical and longitudinal
d. ) 1-4 mm in length

Answer 89

A

Acute repair combined with ACL reconstruction:

◾traditional literature report higher healing rates with concurrent ACL reconstruction

◾current literature shows no difference in healing for 2nd generation all-inside repairs with/without concomittant ACL reconstruction

Answer 90

A

70-95% successful
highest success when done with concomitant ACL recon
poor results with untreated ACL-deficiency (30%)

Answer 91

A

Indications:
◾young patients with near-total meniscectomy –> especially lateral
Contraindications
◾inflammatory arthritis
◾instability
◾marked obesity
◾grade IV chondrosis (if not concurrently addressed)
◾malalignment (if not concurrently addressed)
◾diffuse arthritis

Answer 92

A

Meniscal transplantation  
1. Outcomes 
◾8-12 months
◾RTS @ 6-9 months 
◾re-tears or extrusion are COMMON 
2. Ten-year follow-up showed: 
◾PERSISTENT IMPROVEMENT in subjective pain and function scores
◾PROGRESSION OF DEGEN CHANGES on radiographs

Answer 93

A

Outcomes
◾20% have significant arthritic lesions and 70% have radiographic changes three years after surgery
◾100% have arthrosis at 20 years
◾severity of degenerative changes is proportional to % of the meniscus that was removed

Answer 94

A

approach ◾standard arthroscopic approach
Technique ◾minimize resection (DJD proportional to amount removed) ◾do not use thermal (heat probes)
Postop ◾early AROM ◾prolonged immob (10/52) is detrimental to healing in a dog model

Answer 95

A

inside-out technique is ‘Gold Standard’

2a. sartorius fascia
2b. retract pes tendons
2c. Semimembranosus
2d. medial gastrocnemius
2e. capsule

3a. IT band
3b. biceps tendon
3c. lateral head of gastrocnemius

Answer 96

A

all-inside technique (suture devices with plastic or bioabsorbable anchors) ◾most common
◾many complications (device breakage, iatrogenic chondral injury)
outside-in repair ◾useful for anterior horn tears
Open repair ◾uncommon except in trauma, knee dislocations

Answer 97

A

Technique
◾vertical mattress sutures are strongest because they capture circumferential fibers
◾healing is enhanced by rasping
Risks
◾SAPHENOUS nn. & vv (medial approach)
◾PERONEAL nn. (lateral approach)
◾POPLITEAL vessels

Answer 98

A

Technique
a. BONE-TO-BONE healing with plugs at each horn or a bridge between horns

b. peripheral VERTICAL MATTRESS sutures
c. Correct sizing of the allograft is essential (commonly based on radiographs, within 5-10% error tolerated)

Answer 99

A

A condition characterized by a local collection of synovial fluid within or adjacent to the meniscus
Epidemiology
a. incidence=◾no studies of the general population; ◾found in 1-4% of MRIs
b. Demographics= ◾most commonly assoc. with a meniscal tear; ◾no trend to increased age

Answer 100

A

Location
◾perimeniscal cysts◾small lesions of fluid within the meniscus
◾parameniscal cysts (e.g., baker cysts) ◾extruded fluid outside the meniscus (most common)

Answer 101

A

Perimeniscal cysts
a) MEDIAL cysts
b) LATERAL (2:1)
c) MEDIAL cysts = post. horn
d) LATERAL cysts = ant. horn or mid-portion
Parameniscal cysts (e.g., baker cysts)
a) MORE common
b) SEMIMEMBRANOSUS and c) MEDIAL HEAD of gastrocnemius

Answer 102

A

mechanism of injury◾meniscal tear functions as a one-way valve;◾synovial fluid extrudes and then concentrates to form gel-like material
Pathoanatomy
a) horizontal and complex tears, usually = PARAmeniscal cysts
b) radial or vertical tears, usually = PERImeniscal cysts
Associated conditions:
a) Chondral injury +/- OCD
b) ACL tear

Answer 103

A

Meniscus composition
◾fibroelastic cartilage
◾interlacing network of collagen, proteoglycan, glycoproteins, and cellular elements
65-75% water
90 % Type I collagen
Stretched-out, C-shape with triangular cross section
Lateral meniscus:◾more circular in shape◾covers larger area of articular surface

Answer 104

A

Blood supply
a.) med inf genicular artery
◾supplies peripheral 20-30% of medial meniscus
b.) Lat inf genicular artery
◾supplies peripheral 10-25% of lateral meniscus
Central 75% of meniscus’ receive nutrition through diffusion

Answer 105

A

May have recent trauma
Symptoms
i. asymptomatic
ii. pain ◾localized to medial/lateral joint line or back of knee
iii. mechanical symptoms
iv. delayed or intermittent knee swelling
v. weakness or claudication (NV impingement)

•Examination

a. ) inspection◾popliteal mass (best seen with knee in ext)
b. ) palpation◾joint line tenderness◾palpable mass
c. ) motion◾crepitus

Answer 106

A

Radiographs should be normal in young pt with acute meniscal injury or cyst

2 MRI findings:
◾cyst with bright T2 signal
◾(i) NECROTIC TISSUE; (ii) NERVE SHEATH tissue and (iii) PUS can all resemble cysts on T2-weighted MRIs
(** IV contrast enhancement may be needed)

Answer 107

A

1a. First-line of Rx for small perimeniscal cysts and parameniscal cysts
1b. Trial of medical therapy to observe patients pain response ◾may be effective in population with degenerative tears
2a. Isolated baker’s cysts in young patient
2b. Poor outcomes in older degenerative mensical tears with associated cysts

Answer 108

A

1a. perimeniscal cysts with an associated tear that is not amenable to repair (e.g., complex, degenerative, radial tear patterns)
1b. Incomplete meniscal resection may lead to recurrence

2a. Symptomatic parameniscal cysts
2b. Incomplete resection may lead to recurrence

Answer 109

A

Abnormal development of the meniscus leads to a hypertrophic and discoid shaped meniscus
Discoid meniscus is LARGER than usual
“POPPING-KNEE syndrome”
Epidemiology
Present in 3-5% of population
Usually LATERAL meniscus
25% bilateral

Answer 110

A

Watanabe Classification
Type I-III
a. Type I: Incomplete
b. Type II: Complete
c. Type III: Wrisberg

** Type III untable as no peripheral attachment other than ligament of Wrisberg**

Answer 111

A

Symptoms
◦pain, clicking, mechanical locking
◦often becomes symptomatic in adolescence
Physical exam
◦mechanical symptoms most pronounced in extension

Answer 112

A

AP and lateral of knee
Findings:
a) wide joint space (up to 11mm)
b) squaring of lateral condyle with cupping of lateral tibial plateau
c) hypoplastic lateral intercondylar spine

Answer 113

A

MRI = study of choice for suspected symptomatic meniscal pathology
Findings (3)
(a) Diagnosis can be made with 3 or more 5mm sagittal images with meniscal continuity (“bow-tie sign”)
(b) Sagittal MRI will show abnormally thick and flat meniscus
(c) Coronal MRI will show thick and flat meniscal tissue extending across entire lateral compartment

Answer 114

A

Nonoperative ◦observation

Indications
◾asymptomatic discoid meniscus without tears

Answer 115

A

Indications
◾pain and mechanical symptoms
◾meniscal tear or meniscal detachment
Technique
◾obtain anatomic looking meniscus with debridement
◾repair meniscus if detached (Wrisberg variant)

Answer 116

A

5-20% of all knee ligamentous injuries
MOI:
(i) Direct blow to proximal tibia with a flexed knee (dashboard injury)
(ii) . noncontact hyperflexion with a plantar-flexed foot
(iii) . hyperextension injury

Answer 117

A

1a. PCL is the primary restraint to POST. TIBIAL TRANSLATION
1b. Functions to prevent HYPERFLEXION/SLIDING
1c. Isolated injuries cause the greatest instability at 90° of FLEXION

Answer 118

A

◦ combined PCL and posterolateral corner (PLC) injuries
◦ multiligamentous knee injuries
◦ knee dislocation

Answer 119

A

◾ PCL def. leads to increased contact pressures in the PFJ & medial compartment due to varus alignment

◾Controversial whether late patellar and MFC chondrosis will develop

Answer 120

A

posterior tibial sulcus below the articular surface
anterolateral medial femoral condyle◾broad, crescent-shaped footprint
Dimensions
◾38 mm in length x 13 mm in diameter
◾PCL is 30% larger than the ACL
4a. Anterolateral bundle
◾tight in flexion
◾strongest and most important for posterior stability at 90° of flexion
4b. Posteromedial bundle
◾tight in extension
◾reciprocal function to the anterolateral bundle
Lig. of Humphrey (ant) / Lig. of Wrisberg (post) ◾originate from the posterior horn of the lateral meniscus and insert into PCL substance

Answer 121

A

Blood supply ◦supplied by branches of the middle geniculate artery and fat pad
Biomechanics
a) strength is 2500 to 3000 N (posterior)

b) minimizes posterior tibial displacement (95%)

Answer 122

A

Grade I (partial) ◾1-5 mm PT translation;◾tibia remains anterior to the femoral condyles

2 Grade II (complete isolated); ◾6-10 mm PT translation; ◾complete injury in which the anterior tibia is flush with the femoral condyles

Grade III (combined PCL and capsuloligamentous) ◾>10 mm posterior tibial translation; ◾tibia is posterior to the femoral condyles and often indicates an associated ACL and/or PLC injury

Answer 123

A

. MCL/LCL and PCL injury
MCL/LCL injury
The medial tibial plateau of a normal knee at rest is 10mm ANTERIOR to the medial femoral condyle
(a) Isolated PCL injuries translate >10-12 mm in neutral rotation and 6-8 mm in internal rotation; (b) combined ligamentous injuries translate >15 mm in neutral rotation and >10 mm in internal rotation

Answer 124

A

Quadriceps active test:
◾attempt to extend a knee flexed at 90° = positive if anterior reduction of the tibia occurs relative to the femur
Dial test
◾> 10° ER asymmetry at 30° & 90° consistent with PLC and PCL injury
◾> 10° ER asymmetry at 30° only consistent with isolated PLC injury

Answer 125

A

AP and supine lateral
Lateral stress view
◾apply stress to ant. tibia with knee flexed to 70°
◾asymmetric posterior tibial displacement indicates PCL injury
◾contralateral knee differences >12 mm on stress views suggest a combined PCL and PLC injury
◾becoming the gold standard in diagnosing and quantifying PCL injuries

Answer 126

A

1a. isolated Grade I (partial) and II (complete isolated) injuries
1b. Quads rehab with focus on knee ext strengthening
1c. RTS in 2-4 weeks

2a. Indications
◾Isolated Grade III injuries
◾surgery may be indicated with bony avulsions or a young athlete
2b.◾extension bracing with limited daily ROM exercises
◾immobilization is followed by quadriceps strengthening

Answer 127

A

PCL repair of bony avulsion fractures or reconstruction

2. High Tibial Osteotomy

Answer 128

A

1) Combined ligamentous injuries:
◦ PCL + ACL or PLC injuries; ◦ PCL + Grade III MCL or LCL injuries

2) Isolated Grade II or III injuries with bony avulsion
3) Isolated chronic PCL injuries with a functionally unstable knee

Answer 129

A

Repair: primary repair of bony avulsion fractures with ORIF
Reconstruction options include
◾tibial inlay vs. transtibial methods
◾single-bundle vs. double-bundle
◾autograft vs. allograft
Allograft is typically utilized with multiple graft choices available:
◾options include - Achilles, B-PT-B, hamstring, and anterior tibialis

Answer 130

A

Good results with ORIF of bony avulsions; Poor result with repair of midsubstance ruptures
PCL < Successful than ACL recon (*residual posterior laxity often exists)
Addressing concomitant ligament injuries

** No outcome studies clearly support one reconstruction technique over the other

Answer 131

A

chronic PCL deficiency
techniques:
- consider medial opening wedge osteotomy to treat both varus malalignment and PCL deficiency
- when performing a high tibial osteotomy in a PCL deficient knee, increasing the tibial slope helps reduce the posterior sag of the tibia

Answer 132

A

Post-operative
- immobilize in extension early and protect against gravity;
- early motion should be in prone position
Rehabilitation
- focus on quadriceps rehabilitation
- avoid resisted hamstring strengthening exercises (ex. hamstring curls) in early rehab
(this is because the hamstrings create a posterior pull on the tibia which increases stress on the graft.)

Answer 133

A

Complications
1. Popliteal artery injury (at risk when drilling the tibial tunnel
lies just posterior to PCL insertion on the tibia, separated only by posterior capsule)
2. Patellofemoral pain/arthritis
due to chronic PCL deficiency

Answer 134

A

The medial collateral ligament is both a primary and secondary valgus stabilizer of the knee
also known as the tibial collateral ligament

Answer 135

A

ACL tears comprise up to 95% of associated injuries
- 20% with grd I MCL injuries
- 52% with grd II MCL injuries
- 78% with grd III injuries
Meniscal tears (up to 5% of isolated MCL injuries are associated with meniscal tears)
Calcification at the medial femoral insertion site
results from chronic MCL deficiency

Answer 136

A

Grade 1 - mild severity
no loss of ligamentous integrity

Grade 2- moderate severity /
partial tear; increased joint laxity; end point found at 30 deg of flex with valgus stress; fibers remain apposed

Grade 3 - severe /complete tear; gross laxity; no end point with valgus stress at 30 deg of knee flex

Answer 137

A

Medial capsulo-ligamentous (a) valgus and external forces at the knee

(b) Composition
- 3 layers which extend from the ant to post midline
- contains both static and dynamic stabilizers

(c) static stabilizers:
- superficial MCL: primary restraint to valgus stress
- deep MCL and posterior oblique ligaments: secondary restraints to valgus stress

(d) dynamic stabilizers
- semimembranosus complex
(consists of 5 attachments; vastus medialis; medial retinaculum; pes anserine muscle group; sartorius; semitendinosus; gracilis

(e) superior medial and inferior medial geniculate arteries

Answer 138

A

incidence:
- isolated injury extremely rare
- 7-16% of all knee ligament injuries when combined with lateral ligamentous complex injuries [particularly PLC injury]

Answer 139

A

LCL characteristics
- tubular, cordlike structure
- dimensions: 3-4mm diameter / 66 mm length
origin = lateral femoral epicondyle
- posterior and proximal to insertion of popliteus
insertion = anterolateral fibula head
- most anterior structure on proximal fibula
- order of insertion from anterior to posterior - LCL → popliteofibular ligament → biceps femoris

Answer 140

A

Blood supply: superolateral and inferolateral geniculate arteries

Answer 141

A

layer 1: Iliotibial tract, biceps, fascia
common peroneal nerve lies btwn layers 1 and 2

layer 2: Patella retinaculum, Patelofemoral ligament

Layer 3:
Superficial: LCL, fabellofibular ligament,

** Inf lat geniculate aa. runs btwn sup/deep

deep: Arcuate lig, coronary lig, popliteus tendon, popliteofibular lig, capsule

Answer 142

A

LCL/PLC injury
based on quantification of lateral joint opening as compared with the normal contralateral knee with varus stress
grade 1+: 0-5 mm lateral opening
grade 2+: 6-10 mm lateral opening
grade 3+: >10 mm lateral opening without an endpoint

Answer 143

A

Due to overstretching the muscle which results in tearing of the muscle fibers of the rectus femoris
Epidemiology ◦ seen more commonly in soccer and football players

3 Pathophysiology:
◦mechanism= ◾sudden, forceful eccentric contraction of the muscle ◾sprinting from standing position◾kicking soccer ball with great force
◦pathoanatomy ◾acute injuries ◾usually more distal on the thigh◾chronic injuries ◾usually occur closer to the muscle origin

Associated conditions ◦avulsion of anterior inferior iliac spine (AIIS) ◾adolescent athletes may have proximal bony avulsion of anterior inferior iliac spine (AIIS) ◾occurs at insertion site of direct head of

Answer 144

A

Anatomy
1. Osteology
◦ anterior inferior iliac spine (AIIS) [◾origin of direct head of rectus femoris muscle]

Muscles
◦rectus femoris
◾crosses hip and knee joint
◾flexes hip and extends knee

Answer 145

A

Treatment : Nonoperative
◦NSAIDS, rest, ice, stretching/strengthening
◾indications: definitive treatment for vast majority

◦ outcomes
◾usually resolves within 4-6 weeks

Answer 146

A

A condition characterized by constriction of the popliteal artery by either:
◦adjacent muscles
◦tendons
◦fibrous tissues
Epidemiology
◦male predominance (about 4:1)
◦patient age typically 25-40 years old

Answer 147

A

Mechanism
◦typically due to underlying anatomic abnormality
Pathophysiology
◦decreased blood flow distal to the popliteal fossa leading to signs and symptoms consistent with compartment syndrome
Prognosis
◦70-100% of pts reported to be asymptomatic after surgery

Answer 148

A

Type I: Medial head of the gastrocnemius is normal but the popliteal artery runs in a aberrant course
Type II: Medial head of the gastrocnemius is located laterally, no deviation of popliteal artery
Type III: There is an abnormal muscle bundle from the medial head of the gastrocnemius that surrounds and constricts the popliteal artery
Type IV: Popliteal artery is entrapped by the popliteus muscle
Type V: Popliteal artery is entrapped by the popliteus muscle

Answer 149

A

Fracture of the femoral neck secondary to repetitive loading of bone, of which there are two types:
◾compression side (inferior-medial neck)
◾tension side (superior-lateral neck)

Answer 150

A

Epidemiology ◦common in runners
Mechanism ◦repetitive loading of femoral neck
Pathophysiology
◦ repetitive loading causes microscopic fractures in the femoral neck ◾crack “initiation”
◦ continued repetitive loading does not allow for healing and stress fracture occurs ◾crack “propagation”
“female athlete triad”
i. amenorrhea ii.eating disorder iii. osteoporosis
◾must be considered in any female athlete with stress fracture •Prognosis ◦dependent upon patient compliance

Answer 151

A

Treatment : Non-weight bearing, crutches and activity restriction)
◾indications = compression side stress fractures with fatigue line <50% femoral neck width

Treatment : ORIF with percutaneous screw fixation
◾indications
◾tension side stress fractures
◾compression side stress fractures with fatigue line >50% femoral neck width
◾progression of compression side stress fractures

** Op technique ◾use three 6.5mm or 7.0mm cannulated screws ◾postop WBAT

Answer 152

A

A condition characterized by reversible ischemia to muscles within a muscular compartment
Epidemiology ◦incidence ◾second most common exercise induced leg syndrome ◾behind medial tibial stress syndrome
Demographics ◾males >females ◾often seen in 3rd decade of life ◾runners or those who run a lot for their sport
location ◾anterior leg compartment most commonly affected (~70%) ◾anterior and lateral leg compartment affected in 10% ◾posterior leg compartment involvement associated with less predictable surgical outcomes

Answer 153

A

Compartment pressure measurement
◦limb should be in relaxed and consistant position ◦required to establish diagnosis
◦three pressure should be measured
1. resting pressure
2. immediate post-exercise pressure
3. continuous post-exercise pressure for 30 minutes

◦diagnostic criteria
◾resting (pre-exercise) pressure > 15 mmHg
◾immediate (1 minute) post-exercise is >30 mmHg and/or
◾post-exercise pressure >20mmHg at 5 minutes
◾post-exercise pressure >15 mmHg at 15 minutes

Near-infrared spectroscopy ◦can show deoxygenation of muscle ◾showed return to normal within 25 minutes of exercise cessation

Answer 154

A

Approximately 7-16% knee ligament injuries are to the lateral ligamentous complex
* *nb: Missed PLC injury diagnosis is common cause of ACL reconstruction failure**

2. Mechanisms: 
◾blow to anteromedial knee
◾varus blow to flexed knee
◾contact and noncontact hyperextension injuries
◾knee dislocation

Associated injuries
◾common peroneal nerve (15-29%)
◾vascular injury

Answer 155

A

static structures
- LCL (most anterior structure inserting on the fibular head)
- popliteus tendon
- popliteofibular ligament
- lateral capsule
- arcuate ligament (variable)
- fabellofibular ligament (variable)
dynamic structures
- biceps femoris (inserts on the posterior aspect of the fibula posterior to LCL)
- popliteus muscle
- iliotibial tract
- lateral head of the gastrocnemius

Answer 156

A

Function

Popliteus works synergistically with the PCL to control external rotation, varus, and posterior translation
Popliteus and popliteofibular ligament function maximally in knee flexion to resist external rotation
LCL is primary restraint to varus stress at 5° (55%) and 25° (69%) of knee flexion

Answer 157

A

Grade I (0-5mm of lateral opening and minimal ligament disruption)

Grade II (5-10mm of lateral opening and moderate ligament disruption)

Grade III (>10mm of lateral opening and severe ligament disruption and no endpoint)

Answer 158

A

gait exam (varus thrust or hyperextension thrust)
varus stress
dial test
external rotation recurvatum
posterolateral drawer test
reverse pivot shift test

** note: peroneal nerve injury
altered sensation to dorsum of foot and weak ankle dorsiflexion
approximately 25% of patients have peroneal nerve dysfunction

Answer 159

A

dial test

> 10° external rotation asymmetry at 30° only consistent with isolated PLC injury
> 10° external rotation asymmetry at 30° & 90° consistent with PLC and PCL injury q

External rotation recurvatum
- positive when lower leg falls into external rotation and recurvatum when leg suspended by toes in supine patient

Answer 160

A

Posterolateral drawer test
- performed with the hip flexed 45°, knee flexed 80°, and foot is ER 15°.
- a combined posterior drawer and external rotation force is then applied to the knee to assess for an increase in posterolateral translation (lateral tibia externally rotates relative to lateral femoral condyle)
Reverse pivot shift test
- knee positioned at 90° and 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° of flexion to a reduced position in full extension (reduction force from IT band transitioning from a flexor to an extensor of the knee)

Answer 161

A

Radiographs
i. may see avulsion fracture of the fibula (arcuate fracture ) or femoral condyle
MRI
i. look for injury to the LCL, popliteus, and biceps tendon
ii. in acute injury may see bone bruising of medial femoral condyle and medial tibial plateau

Answer 162

A

Nonoperative : immobilize knee in full extension with PWB for ~2 weeks
i. indications: in isolated PLC Grade I or II injuries
ii. followed by progressive functional rehabilitation focusing on quad strengthening with return to sports in 8 weeks

Answer 163

A

PLC repair : indications

only in isolated PLC injuries with bony or soft tissue avulsion
able to operate within 2 weeks of injury

PLC recon: indications

used for most grade III isolated injuries
when repair not possible or has poor tissue quality

Answer 164

A

activity-related anterior knee pain associated with focal patellar-tendon tenderness - also known as “jumper’s knee”

Answer 165

A

Incidence
- up to 20% of jumping athletes

Demographics / risk factors

males > females
volleyball most common
more common in adolescents/young adults
- > quadriceps tendinopathy is more common in older adults
poor quadriceps and hamstring flexibility

Answer 166

A

Blazina classification system

phase I - pain after activity only

phase II - pain during and after activity

phase III - persistent pain with or without activities / deterioration of performance

Answer 167

A

Symptoms: insidious onset of anterior knee pain at inferior border of patella
(pain with prolonged flexion (“movie theater sign”)
Basset’s sign
- tenderness to palpation at distal pole of patella in full extension
- no tenderness to palpation at distal pole of patella in full flexion

Answer 168

A

Radiographs: may show inferior traction spur (enthesophyte) in chronic cases
Ultrasound: thickening of tendon/hypoechoic areas
MRI: tendon thickening /more diagnostic than presence of edema/ increased signal intensity on both T1 and T2 images /
loss of the posterior border of fat pad in chronic cases

Answer 169

A

incidence =◾rare injury◾even less common as an isolated injury
Most common in 2nd to 4th decades
(a) horseback riding; (b) parachuting; (c) fall onto a flexed and aDducted knee
(i) posterior hip dislocation (flexed knee and hip);
(ii) open tib-fib fx
(iii) other fx about the knee and ankle

Answer 170

A

Ogden classification
Types
Type 1= subluxation Type 2=anterolateral - most common
Type 3= posteromedial
Type 4= superior

Answer 171

A

Inflammation of the suprapatellar tendon of the quadriceps muscle
8:1 male-to-female ratio (◾more common in adult athletes)
Jumping sports (◾basketball◾volleyball◾athletics (e.g., long jump, high jump, etc)
Associated conditions:
◦ Jumper’s knee (◾patellar tendonitis)
◦ Quadriceps tendinosis ◾chronic quad tendon degen with no inflamm

Answer 172

A

◦quadriceps muscles ◾rectus femoris, vastus medialis, vastus lateralis, vastus intermedius
◦quadriceps tendon
common trilaminar tendon of quadriceps muscles ◾anterior layer = rectus femoris
◾middle layer = vastus medialis and vastus lateralis
◾deep layer = vastus intermedius
medial, lateral and peripatellar arcades
Innervated by muscular branches of the femoral nerve (L2, L3, L4)

Answer 173

A

◦acute traumatic ◾occurs equally by gender ◾may occur from a direct blow (ex. helmet to knee collision in football)

◦chronic patholaxity ◾recurrent subluxation episodes ◾occurs more in women ◾associated with malalignment

◦habitual ◾usually painless ◾occurs during each flexion movement ◾pathology is usually proximal (e.g. tight lateral structures - ITB and vastus lateralis)

Answer 174

A

General factors
◾ligamentous laxity (Ehlers-Danlos syndrome)
◾previous patellar instability event
◾”miserable malalignment syndrome”

2a. Anatomical factors: 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

2b. Anatomical factors: Muscle ◾dysplastic vastus medialis oblique (VMO) muscle
◾overpull of lateral structures (iliotibial band / vastus lateralis)

Answer 175

A

“miserable malalignment syndrome”

◾a term named for the 3 anatomic characteristics that lead to an increased Q angle

   1. femoral anteversion
   2. genu valgum
   3. external tibial torsion / pronated feet

Answer 176

A

Passive stability
◾Medial patellofemoral ligament (MPFL)
◦ primary restraint in first 20 degrees of knee flexion
◦ Insertion on femur (between medial epicondyle and adductor tubercle) is usual site of avulsion of MPFL

◾Patellar-femoral bony structures account for stability in deeper knee flexion)
◦trochlear groove morphology, patella height, patellar tracking

Dynamic stability
◾Provided by vastus medialis (attaches to MPFL)

Answer 177

A

Q angle is the angle formed by a line drawn from the ASIS to central patella and a second line drawn from central patella to tibial tubercle;

an increased Q angle is a risk factor for patellar subluxation;
normally Q angle is 14 deg for males and 17 deg for females (Agliettis et. al. Clin. Ortho 1983)

Answer 178

A

increase in passive patellar translation ◾measured in quadrants of translation (midline of patella is considered “0”), and also should be compared to contralateral side
◾normal motion is <2 quadrants of patellar translation ◾lateral translation of medial border of patella to lateral edge of trochlear groove is considered “2” quadrants and is considered abnormal amount of translation
J sign
◾excessive lateral translation in extension which “pops” into groove as the patella engages the trochlea early in flexion
◾associated with patella alta

Answer 179

A

lateral views
XR signs trochlear dysplasia
◾crossing sign (trochlear groove lies in same plane as anterior border of lateral condyle; represents flattened trochlear groove)
◾double contour sign (ant border of lat condyle lies ant to ant border of med condyle - represents convex trochlear groove/hypoplastic medial condyle)
◾supratrochlear spur (arises in proximal aspect of trochlea)

Answer 180

A

Patellar height (patella alta vs. baja)
i) Blumensaat’s line (should extend to inferior pole of the patella at 30 degrees of knee)
ii) Insall-Salvati method (normal 0.8 to 1.2)
iii) Blackburne-Peel method (normal 0.5-1.0)
iv) Caton Deschamps (normal 0.6 and 1.3)
v) Plateau-patella angle (normal between 20 and 30 degrees)
Sunrise/Merchant/Skyline views ◾best to assess for lateral patellar tilt
◾lateral patellofemoral angle (normal is an angle that opens laterally)
◾angle between line along subchondral bone of lateral trochlear facet + posterior femoral condyles
◾normal > 11°
◾congruence angle (normal is -6 degrees)

Answer 181

A

Measured on CT images, the TT-TG (Tib-Tub to Trochlear-groove) distance measures:

The distance between 2 perpendicular lines from the posterior cortex to the tibial tubercle and the trochlear groove

> 20mm usually considered abnormal

Answer 182

A

NSAIDS, activity modification, and physical therapy

Indications:
◾mainstay of treatment for first time patellar dislocator (without any loose bodies or intraarticular damage)
◾habitual dislocator

Techniques:
1. short-term immob then 6/52 controlled motion
2. emphasis on strengthening ◾closed chain short arc quads ex’s ◾Quad strengthening ◾core and hip strengthening to improve limb positioning and balance (hip abductors, gluteals, and abdominals)
3. Patellar stabilizing sleeve or “J” brace
◾consider knee aspiration for tense effusion ◾positive fat globules indicates fracture

Answer 183

A

◾Arthroscopic debridement (removal of loose body) vs Repair with or without stabilization
ind: OCD/loose body

◾MPFL repair
ind: acute 1st disloc with bony fragment

◾MPFL reconstruction with autograft vs allograft
ind: recurrent instability / no sign. underlying malalignment

◾Fulkerson-type osteotomy (anterior and medial tibial tubercle transfer)
ind: may be used in addition to MPFL or in isolation for significant malalignment / TT-TG >20mm on CT

◾tibial tubercle distalization
ind: patella alta

◾lateral release
ind: isolated release no longer indicated for instability / only indicated if there is excessive lateral tilt or tightness after medialization

◾trochleoplasty
ind: rarely addressed (in the USA) even if trochlear dysplasia present / may consider in severe or revision cases

Answer 184

A

Improper tracking of patella in trochlear groove caused by tight lateral retinaculum
◦leads to excessive lateral tilt without excessive patellar mobility
Pain with stair climbing / ‘theatre sign’ (pain with sitting for long periods of time)
Physical exam ◦pain with compression of patella and moderate lateral facet tenderness ◦inability to evert the lateral edge of the patella

Answer 185

A

patellar tilt in lateral direction

Answer 186

A

Condition characterized by idiopathic articular changes of the patella
◦term is now falling out of favor
◦more commonly grouped together with a number of pathological entities known as ◾”anterior knee pain” or
◾”patellofemoral syndrome”

Answer 187

A

Outerbridge Classification

2. Type 1: Softening / Type 2: Fissures / Type 3: Crabmet changes / 4: Exposed chondral bone

Answer 188

A

Most common bursitis of the knee (bursa anterior to patella)
◾excessive kneeling◾common in wrestlers ◾concern for septic bursitis in wrestlers
Septic=20% ; Aseptic=80%

Answer 189

A

Nonoperative ◦compressive wrap, NSAIDs, +/-aspiration and immobilization for 1 week ◾indications=most cases; ◾technique: corticosteroid use is controversial

Operative ◦bursal resection
◾indications =rare

Answer 190

A

Incidence ◾< 0.5% of the US population per year
demographic ◾most commonly in 3rd and 4th decade ◾male > female
location: ◾quadriceps tendon rupture > patella tendon rupture

Answer 191

A

Caused by weakening of collagen structure - effected by:

1. Systemic   
◾systemic lupus erythematous
◾rheumatoid arthritis
◾chronic renal disease
◾diabetes mellitus

Local
◾patellar degeneration (most common)
◾previous injury
◾patellar tendinopathy
Other
◾corticosteroid injection

Answer 192

A

Pathoanatomy : 3 patterns of injury
i. avulsion with or without bone from the proximal insertion/inferior pole of patella (most common)
ii. midsubstance
iii. distal avulsion from the tibial tubercle

** note: rupture is usually the result of end stage or long-standing chronic tendon degeneration **

Outcome: most important factor is timing of repair

Answer 193

A

Epidemiology:
◦incidence ◾5-10% of people > 40 years old have high grade chondral lesions

Location:
◾chronic ACL tear -> anterior aspect of lateral femoral chondyle and posterolateral tibial plateau
◾osteochondritis dissecans ◾70% of lesions found in posterolateral aspect of medial femoral condyle

Answer 194

A

Outerbridge Arthroscopic Grading System
◾Grade 0=Normal cartilage; 1=Softening and swelling; 2=Superficial fissures; 3=Deep fissures, without exposed bone; 4= Exposed subchondral bone)
ICRS (International Cartilage Repair Society) Grading System
◾Grade 0=Normal; 1= Nearly normal (superficial lesions); 2=Abnormal (lesions extend < 50% of cartilage depth); 3=Severely abnormal (>50% of cartilage depth); 4=Severely abnormal (through the subchondral bone)

Answer 195

A

MRI ◾most sensitive for evaluating focal defects

Views
◾Fat-suppressed T2, proton density, T2 fast spin-echo (FSE) offer improved sensitivity and specificity over standard sequences
◾dGEMRIC (delayed gadolinium-enhanced MRI for cartilage) and T2-mapping are evolving techniques to evaluate cartilage defects and repair

Answer 196

A

Demographic ◾women:men 3:1
◾more common in women <55 years with risk factors ◾reported to be found after knee arthroscopy in middle-aged women
Location ◾typically involves more than one compartment of the knee or even the metaphysis ◾80% are bilateral ◾multifocal lesions are not uncommon

Answer 197

A

Risk factors
◾alcoholism
◾dysbaric disorders (decompression sickness, “the bends”)
◾marrow-replacing diseases (e.g. Gaucher’s disease)
◾sickle cell disease
◾hypercoagulable states
◾steroids (either endogenous or exogenous)
◾SLE
◾inflammatory bowel disease
◾transplant patient
◾virus (CMV, hepatitis, HIV, rubella, rubeola, varicella)
◾protease inhibitors (type of HIV medication)
◾trauma
Prognosis = self-limiting condition

Answer 198

A

◾most common in middle age and elderly◾affects females (>55yo) more frequently than males
◾99% of patients have only one joint involved ◾usually epiphysis of medial femoral condyle
◾ may represent a subchondral insufficiency fracture ◾ also believed to be caused by a meniscal root tear

Answer 199

A

Lesion is crescent shaped
DDx
i. osteochondritis dissecans (more common on lateral aspect of medial femoral condyle in adolescent males)

ii. transient osteoporosis (more common in young to middle age men)
iii. bone bruises and occult fractures (associated trauma, bone fragility or overuse)
iv. idiopathic osteonecrosis of the knee (lesion is not crescent shaped)

Answer 200

A

Nonoperative ◦NSAIDs, narcotics, PWB ◾indications=mainstay of treatment as most cases resolve

Operative
◦arthroplasty
◦high tibial osteotomy

Answer 201

A

demographics ◾more common in boys◾age bracket = boys 12-15y / girls 8-12y
Location: ◾bilateral in 20-30%
Risk factors: ◾jumpers (basketball, volleyball) or sprinters
Self-limiting but does not resolve until growth has halted

5.

Answer 202

A

◦age <11y, tubercle is cartilaginous

◦age 11-14y, apophysis forms

◦age 14-18y, apophysis fuses with tibial epiphysis

◦age >18y, epiphysis (and apophysis) is fused to rest of tibia

Answer 203

A

Symptoms
◦pain on anterior aspect of knee
◦exacerbated by kneeling

Physical exam
◦inspection ◾enlarged tibial tubercle ◾tenderness over tibial tubercle
◦provocative test ◾pain on resisted knee extension

Answer 204

A

Sinding-Larsen-Johansson syndrome ◦chronic apophysitis or minor avulsion injury of inferior patella pole
◦occurs in 10-14yr old children, especially children with cerebral palsy
Osteochondroma of the proximal tibia
Tibial tubercle fracture
Jumpers knee

Answer 205

A

Overuse injury causing anterior knee pain at the inferior pole of patella at the proximal patella tendon attachment ◦similar to Osgood-Schlatter’s disease which is at the distal attachment of the patella tendon
◦different from Jumper’s Knee which is tendonitis of the patella tendon

Answer 206

A

Epidemiology ◦demographics ◾more common in adolescence

2 Location ◾patellar tendon insertion at the inferior pole of the patella

Pathophysiology ◦chronic injury
◦similar pathogenesis to Osgood-Schlatter
◦overuse causes a traction apophysitis

Answer 207

A

◾juvenile form (open physes) ◾occurs at age 10-15 while the physis is still open
◾adult form (skeletal maturity)
◾knee (most common) ◾posterolateral aspect of medial femoral condyle (70% of lesions in knee) ◾capitellum of humerus
◾talus

Answer 208

A

1. Pathophysiology 
mechanism/etiology may be: 
◾hereditary
◾traumatic
◾vascular
     - cause of adult form is thought to be vascular

Pathoanatomic cascade
◾softening of the overlying articular cartilage with intact articular surface
◾early articular cartilage separation
◾partial detachment of lesion
◾osteochondral separation with loose bodies

Answer 209

A

Mechanism direct trauma or crushing (common in contact sports)
Pathoanatomy ◦hematoma occurs into area surrounding iliac wing ◾and can cause bleeding into hip abductor muscles
(** note : rule out avulsion of the iliac apophysis ◾in adolescent patients)

Answer 210

A

◦sartorius
◦tensor fascia lata
◦gluteus medius
◦abdominal muscles: ◾transverse or oblique muscles

Answer 211

A

Presentation

a) Symptoms =pain near iliac crest
b) Physical exam
◦contusion and hematoma near iliac crest
◦affected hip weakness
◦decreased range of motion

Imaging
a) Radiographs
◦usually unremarkable
b) MRI
◦usually unremarkable ◦can show large hematoma

Answer 212

A

Treatment = Nonoperative ◦rest, NSAIDS, steroid injections, and therapy ◾indications =main line of treatment
◾technique = medications / NSAIDs and muscle relaxants may be beneficial
◾therapy= focused on stretching the muscles about the iliac crest ; place affected leg on maximum stretch
◾steroid injections - corticosteroid injection directed near iliac crest
◾return to play –> additional padding during return to play

Answer 213

A

Introduction
1. ASIS avulsions occur in young athletes through the physis

Mechanism
a) indirect trauma
b) sartorius
c) TFL
d) hip extension

Answer 214

A

Anatomy : Muscles that originate from ASIS

sartorius (femoral n.)
tensor fascia lata (superior gluteal n.)

Answer 215

A

athlete will often report a pop or snap at the time of injury
may complain of weakness ◾may be confused or misdiagnosed as an acute muscle strain
weakness to hip flexion and knee extension
Xray: displaced fractures usually can be seen on radiographs ◾may be missed due to location and small size of bony fragment
CT or MRI ◦can be obtained to confirm the diagnosis

Answer 216

A

Nonoperative ◦rest, protected weight bearing with crutches, and early ROM and stretching
◾indications ◾most cases
Operative ◦ORIF of avulsion fracture ◾indications
◾fractures with displacement of > 3 cm
◾painful nonunions

Answer 217

A

An apophyseal avulsion injury seen in adolescent athletes (Occurs most often in sports involving kicking)
14-17 years
M > F
Mechanism ◾typically occurs due to eccentric contraction of the rectus femoris (femoral n.)
◦as hip extends and knee is flexed
◦causes avulsion of its anatomic origin off the pelvis

Answer 218

A

Anterior Inferior Iliac Spine Avulsion (AIIS)

Anterior inferior iliac spine ◦a bony prominence just above acetabulum
◦is the origin of the direct head of the rectus femoris (femoral n.)

Answer 219

A

Anterior Inferior Iliac Spine Avulsion (AIIS)

History ◦sudden “pop” in pelvis
Symptoms ◦pain and weakness
Physical exam ◦antalgic gait
◦anterior hip pain and hip flexion weakness
Imaging: Radiographs ◦show avulsion of AIIS

Answer 220

A

Anterior Inferior Iliac Spine Avulsion (AIIS)

Treatment : Nonoperative ◦bed-rest, ice, activity modification
◾indications = almost all treated nonoperatively
◾technique = hip flexed for 2 weeks (position lessens stretch of affected muscle and apophysis) ; follow with guarded weight bearing for 4 week
Complications
•Loss of reduction
•Delayed union

Answer 221

A

Inflammation of the pubic symphysis caused by repetitive trauma
Epidemiology ◦demographics ◾common in soccer, hockey, football and running
Pathophysiology ◦mechanism ◾repetitive microtrauma to the pubic symphysis by
◾sports involving repetitive kicking
◾sports involving hip repetitive adduction/abduction

Answer 222

A

Osteitis Pubis: Anatomy

Pubic symphysis ◦osteology ◾located at the anterior articulation between each hemipelvis; ◾composed of articular cartilage-covered rami separated by fibrocartilage disc
Muscles : regional attachments
◾adductors (adductor magnus; brevis; longus) ◾gracilis ◾rectus abdominis◾pectineus
Ligaments
◾superior pubic ligament ◾inferior pubic ligament◾anterior pubic ligament ◾posterior pubic ligament

NOTE: Biomechanics ◾very stable joint
◾strong ligamentous support limits motion

Answer 223

A

Vague, ill-defined pain is anterior pelvic region ◾worse with activities involving hip adduction/abduction at the anterior pelvis
◾may have spasms with hip adduction
Physical exam
◦palpation = localized tenderness directly over the pubic symphysis
•Athletic pubalgia ; •Stress fracture of the pubic rami; •Stress fracture of the femoral neck; •Inguinal hernia; •Oncologic disease (rare)

Answer 224

A

recommended views ◾AP of pelvis
XR findings= ◾osteolytic pubis with bony erosions and often times diastasis of the symphysis ◾degenerative changes within the joint can be seen

3 MRI ◦bone marrow edema found early

4 Bone scan ◦increased activity in area of pubic symphysis

Answer 225

A

Nonoperative
◾Details=NSAIDS, rest, activity modification
◾indications=treatment for vast majority of cases;
◾modalities=steroid injections are controversial
Nonoperative: outcomes
◾self-limiting process which usually resolves with non-operative treatment ◾may take several months to resolve

Answer 226

A

Clinical entity characterized by anterior pelvic pain or groin pain ◦more commonly referred to as “sports hernia” syndrome
◦condition not fully understood

2 Epidemiology
◾males > females
◾common in hockey players and soccer players
◾location=muscles of abdominal wall or adductor longus

Pathophysiology ◦mechanism of injury ◾may be caused by acute trauma or microtrauma caused by overuse
◾thought to be a caused by abdominal hyperextension and thigh abduction

Answer 227

A

lower abdominal pain and inguinal pain at extremes of exertion
tenderness to adductor longus
pain with valsalva and situps
Obtain radiographs, MRI, and bone scan to rule out other cause of symptoms
Must be differentiated from subtle true inguinal hernia

Answer 228

A

Nonoperative ◦rest and physical therapy for 6-8 weeks ◾indications ◾ first line of treatment
Operative
(i) pelvic floor repair (hernia operation) vs. adductor / rectus recession
◾indications ◾after extensive nonoperative treatment fails
(ii) decompression of the genital branch of the genitofemoral nerve
◾indications ◾after extensive nonoperative treatment fails

Answer 229

A

A condition characterized by sciatic symptoms (leg pain) due to extrapelvic sciatic nerve compression at the hip (sometimes called deep gluteal syndrome)
Sciatic nerve entrapment occurs:
a. ) anterior to piriformis muscle or posterior to obturator internus/gemelli complex
b. ) at level of ischial tuberosity
◾bipartite piriformis◾variations of sciatic nerve path ◾tumors ◾aneurysm of inferior gluteal artery
femoroacetabular impingement ◾decreased internal rotation may contribute to contractures of short external rotators and compression on sciatic nerve

Answer 230

A

Exits
◾inferior to piriformis
◾superior to superior gemellus

2. Muscles (superior to inferior) 
◾piriformis 
◾superior gemellus 
◾obturator internus 
◾inferior gemellus  
◾obturator externus 
◾quadratus femoris

Answer 231

A

Symptoms
◦pain in the posterior gluteal region and migrating down the back of the leg
◦pain may be burning or aching in nature similar to sciatica symptoms
FAIR test
◾Flexion, Adduction, and Internal Rotation of hip can reproduce symptoms
◾maneuver places piriformis muscle on tension

Answer 232

A

Radiographs = unremarkable
MRI = usually unremarkable ; lumbar MRI helpful to rule out spine as cause of compression of sciatic nerve
Electrodiagnostic studies ◦can document functional impairment of sciatic nerve

Answer 233

A

Nonoperative ◦rest, NSAIDS, muscle relaxants, PT, steroid injections ◾indications=first line of treatment
◾technique= focused on stretching the piriformis muscle and short external rotators
◾corticosteroid injection directed near the piriformis muscles
Operative ◦piriformis muscle release and external sciatic neurolysis ◾indications= only indicated in refractory cases after failed conservative measures

Answer 234

A

A condition characterized by a snapping sensation in the hip ◦caused by motion of muscles and tendons over bony structures around the hip joint
Epidemiology: common in athletes and dancers in their teens or twenties

Answer 235

A

3a. External snapping hip
◾caused by iliotibial tract sliding over greater trochanter

3b. Internal snapping hip ◾most common form
◾caused by iliopsoas tendon sliding over
     ◦femoral head 
     ◦prominent iliopectineal ridge
     ◦exostoses of lesser trochanter
     ◦iliopsoas bursa

3c. Intra-articular snapping hip
◾caused by:
◦loose bodies in the hip (may be seen with synovial chondromatosis)
◦ labral tears

Answer 236

A

Symptoms
i. snapping sensation in and around hip joint
◾may be painful or painless
◾patient often able to reproduce snapping
◾aggravated by activity
ii. clicking or locking sensation ◾more indicative of intra-articular pathology

Answer 237

A

external snapping hip is often visible while internal snapping is not, but may be audible (“external snapping one can see from across the room, while internal one may hear from across the room”)
tightness of tensor fascia lata diagnosed with Ober’s Test ◾limited hip adduction when hip held in extension
Internal snapping hip ◾snapping is reproduced by passively moving hip from a flexed and externally rotated position to an extended and internally rotated position
External snapping hip ◾palpate greater trochanter as hip is actively flexed ◾applying pressure will likely stop snapping, confirming diagnosis

Answer 238

A

Radiographs ◦recommended views ◾AP pelvis/hip; ◦findings ◾usually normal◾may be useful to rule-out synovial chondromatosis
Ultrasound ◦dynamic study which may demonstrate the snapping band in either internal or external snapping
◦may be used to localize a diagnostic challenge injection into the trochanteric bursa (external), the iliopsoas sheath (internal), or intra-articular space.

3 MRI ◦useful to rule-out intra-articular pathology; ◦often performed as an arthrogram study; ◦may show inflamed bursa

Iliopsoas bursography ◦iliopsoas tendon visualized under fluoroscopy after bursa injected with contrast dye
◦may add therapeutic injection after diagnosis is confirmed

Answer 239

A

Nonoperative ◦often internal and external snapping are painless and require no treatment:
◦activity modification ◾indications ◾acute onset (<6 months) of painful internal or external snapping hip
◦physical therapy, injection of corticosteroid ◾indications ◾persistent, painful snapping interfering with activities of daily living

2a. Operative: excision of greater trochanteric bursa with Z-plasty of iliotibial band ◾indications= painful external snapping hip that has failed nonoperative management OR snapping after total hip replacement
2b. Release of iliopsoas tendon ◾indications =painful internal snapping hip that has failed of nonoperative management
2c. Hip arthroscopy with removal of loose bodies or labral debridement/repair ◾indications = intra-articular snapping hip that has failed nonoperative management and has MRI confirmation of i) loose bodies ii) labral tear

Answer 240

A

Excision of greater trochanteric bursa with Z-plasty of iliotibial band ◦technique ◾lengthen the iliotibial band by Z-plasty
◾may be done endoscopically

2 Iliopsoas tendon release
a) approach: (i) anterior; (ii) medial; (iii) ilioinguinal; (iv) iliofemoral

b) avoid hip flexion strengthening for 6 weeks

Answer 241

A

refers to transient brachial plexus neuropraxia ◦can be serious if they are recurrent or long lasting
Epidemiology ◦common in collision sports such as football
Having 1 stinger increases risk of another by 3X
Pathoanatomy:
i. Traction injury
◾occurs by downward displacement of arm and bending of neck away from side of injury
ii. Compression injury
◾occurs by lateral head turning toward affected side
iii. Direct blow
◾can cause injury with blow at Erb’s point superior to the clavicle

Answer 242

A

Symptoms: unilateral tingling in arm IS NOT typically isolated to a single dermatome
Usually resolve quickly in 1-2 minutes
Physical exam = FULL cervical ROM
Physical exam = NO tenderness
Physical exam= unilat transient weakness in C5, C6 muscles (deltoid, biceps)
Physical exam = can have positive Spurling test

Answer 243

A

Radiographs ◦usually unremarkable
◦C-spine images indicated with recurring symptoms ◾to rule out fx and cervical stenosis
MRI ◦indicated whenever symptoms are bilateral (inconsistent with stinger) ◾to rule out cervical spine pathology such as herniated disc or cervical stenosis
EMG ◦indicated if symptoms persist after 3 weeks ◾will show abnormalities in roots, cords, trunks, and peripheral nerves

Answer 244

A

Nonoperative : return to play
a player may return to play when:
(a) complete resolution of symptoms
(b)normal strength and range of motion
contraindications to return to play include ◾recurring symptoms (until cervical spine xrays are obtained)
Prevention ◦try different neck collars for football players

Answer 245

A

still to be done

Answer 246

A

10%
Approx 330K sports-related head injuries/year
( NOTE : head injuries are the leading cause of sports deaths; ◦helmet use associated with decreased rates of head and neck injuries)
Associated conditions ◦rule out associated neck injuries

Answer 247

A

dura mater (outside)
◾epidural hematoma
◾subdural hematoma
arachnoid (middle)
◾subarachnoid hematoma
Pia mater (inside)

Answer 248

A

Grade I: No LOC and symptoms of confusion last less than 15 minutes

Grade II: No LOC and symptoms of confusion last greater than 15 minutes

Grade IIIa: Brief loss of consciousness (measured in seconds)

Grade IIIb: Brief loss of consciousness (measured in minutes)

Answer 249

A

Symptoms ◦headache and dizziness most common symptoms ◦amnesia (memory loss)
CT ◦usually normal ◦rule out intracranial hemorrhage
◾SUBDURAL hematoma most common
◾epidural, subarachnoid, intracerebral bleeds also possible
◾CT required if patient is unconscious for GREATER THAN 5 MINUTES

Answer 250

A

SAC Test ◦orientation, memory, concentration, exertional delayed recall
ImPACT
◦a computer-based test that assess the users attention, memory, and processing speed
◦comparison is made to baseline scores or historical controls
◦useful tool in guiding treatment and return to play decisions
Memory testing ◦antegrade and retrograde must be tested

4 Balance error scoring system (BESS)

Answer 251

A

Second impact syndrome ◦second minor blow to head before initial symptoms resolve ; ◦due to loss of autoregulation of the brain’s blood supply ◦50% mortality rate ◦affects adolescent males
Epidural bleeding ◦commonly have a lucid period before neurologic decline
◦neurosurgical decompression and seizure prophylaxis indicated
Cumulative effects ◦cumulative effects of repeated concussions is controversial
Postconcussion syndrome ◦headache, confusion; ◦RTP contraindicated

Answer 252

A

Nonoperatve ◦same day return to play is NOT indicated in patients diagnosed with concussion
Graduated return to play: indications ◾any athlete <18 years of age
◾elite athletes of any age without team physicians experienced in concussion management

3. return to play contraindicated until further evaluation   ◾indications ◾LOC
◾prior Grade 1 concussion in same season
◾symptoms > 15 minutes
◾positive exertional stress test
◾amnesia
◾postconcussion syndrome

Prevention ◦includes enforcing proper head gear
◦minimizing premature return to play

Answer 253

A

An overuse injury where normal or abnormal bone is subjected to repetitive stress, resulting in microfractures
Commonly seen in runners and military recruits / seen after change in training routine
Linear microfractures in trabecular bone from repetitive loading
Callus formation->woven bone->endochondral bone formation

Answer 254

A

Change in exercise routine
◦ Onset of symptoms often insidious ◦ Symptoms initially worse with running, then may develop symptoms with daily activities
Pain directly over fracture

Answer 255

A

AP and lateral
lateral xray may show “dreaded black line” anteriorly indicating tension fracture from posterior muscle force
◾endosteal thickening
◾periosteal reaction with cortical thickening
Technetium Tc 99m bone scan ◦findings ◾focal uptake in cortical and/or trabecular region
◾marrow edema
◾earliest findings on T2-weighted images ◾periosteal high signal
◾T1-weighted images show linear zone of low signal

Answer 256

A

Non-op
◾indications=most cases
◾technique = avoids NSAIDs (slows bone healing)
; consider bone stimulator
Operative
◾ IMN
◾indications = if “dreaded black line” is present, especially if it violates the anterior cortex (nb: fxs of ant cortex of tibia have highest likelihood of delayed healing or non-union)

Answer 257

A

Overuse injury or repetitive-load injury of the shin area that includes:
i) medial (posteromedial) tibial stress syndrome ◾most common
ii) anterior (anterolateral) tibial stress syndrome
10-15% running; 60% leg pain syndromes
distal and posteromedial tibia

Answer 258

A

◾runners without enough shock absorption (running on cement or uneven surfaces, improper running shoes)
◾training errors (sudden increase in training intensity and duration)
◾running >20 miles/week
◾hill training early in the season
◾history of previous lower extremity injuries
◾over-pronation or increase internal tibial rotation

Answer 259

A

◾tibialis anterior
◾tibialis posterior and soleus
Associated conditions
i. female athlete triad (critical to diagnose and treat)
ii. tibial stress fractures (females have 1.5-3.5 > risk of progression to stress fractures)

Answer 260

A

Anterior tibial stress syndrome->Periosteum->Vague, diffuse pain along anterolateral tibia, worse at beginning of exercise, decreases during training
Medial tibial stress syndrome->Periosteum->Vague, diffuse pain along middle-distal tibia, worse at beginning of exercise, decreases during training
Tibial or fibular stress fracture->Bone->Pain with running, point tenderness over fracture site, “dreaded black line” on lateral xray
Exertional compartment syndrome->Muscle and fascia->Symptoms begin 10min into exercise and resolve 30min after exercise, sensory or motor loss, elevated anterior compartment pressures
Leg Tendinopathy->Tendon->May be Achilles tendon, peroneal tendon, or tibialis posterior
Sural or SPN entrapment->Nerve->Dermatomal distribution of symptoms
Lumbar radiculopathy->Nerve->Worse with lumbar tension position (sitting)
Popliteal artery entrapment->Blood Vessel->Diagnosed with vascular studies

Answer 261

A

Symptoms
i. vague, diffuse pain along middle-distal tibia that decreases with running (early stage) ◾differentiate from exertional compartment syndrome, for which pain increases with running

ii. earlier onset of pain with more frequent training (later stages)

Answer 262

A

Physical exam

i. Tenderness along posteromedial border of tibia ◾4cm proximal to medial malleolus, extending proximally up to 12cm
ii. pes planus
iii. tight Achilles tendon
iv. weak core muscles
v. provocative test ◾pain on resisted plantar flexion

Answer 263

A

indications
◾exclude stress fracture
findings
◾conventional XRs are normal in first 2-3weeks
◾long-term changes include periosteal exostoses
(note: differentiate from stress fracture, which shows “dreaded black line” )

Answer 264

A

Indications
◾exclude stress fracture
Findings
◾diffuse, longitudinal increased uptake along posteromedial border of tibia in delayed phase (Phase 3) but…
◾normal findings on Phase 1 (flow phase) and blood pool phase (Phase 2)
(note: theses findings differentiate from stress fracture, which has focal, intense hyperperfusion and hyperemia in Phase 1 and 2, and focal, fusiform uptake in Phase 3)

Answer 265

A

Techniques
a) activity modification ◾decreasing running distance, frequency and intensity by 50%
◾use low-impact and cross-training exercises during rehab period
◾regular stretching and strengthening
◾run on synthetic track
◾avoid running on hills, uneven or hard surfaces

b) shoe modifications ◾change running shoes every 250-500miles as shoes lose shock absorbing capacity at this distance
◾orthotics may be helpful in patients with pes planus

c) therapy
◾focus on strengthening of invertors and evertors of the calf

d) other
◾local phonophoresis with corticosteroids may be effective

Answer 266

A

Deep posterior compartment fasciotomy + release of painful portion of periosteum
Indications = failed nonoperative treatment
Outcomes = variable results, not likely to cause complete resolution of symptoms

Answer 267

A

1. Spectrum of injuries include  
◾ligament sprains 
◾burners / stingers 
◾spear tackler's spine  
◾cervical fxs
◾transient quadriplegia ◾quadriplegia

Answer 268

A

Transient quadriplegia:
◾neuropraxia of the cervical cord
◾bilateral upper and lower extremity pain, parasthesias, and weakness
◾symptoms resolve within minutes to hours

Answer 269

A

definition ◾developmental narrowing (stenosis) of the cervical canal
◾persistent straightening or reversal of the normal cervical lordotic curve
◾concomitant posttraumatic roentgenographic abnormalities of the cervical spine
◾documentation of having employed spear tackling techniques
Rx= contraindication to play in contact sports

Answer 270

A

axial load (compression) with flexion of the spine
most injuries in contact sports occur during tackling of another player
◾”spear tackling” = most common mechanism in football
◾can lead to gradual cervical stenosis and loss of cervical lordosis

Answer 271

A

previous trauma to cervical spine (fractures, ligamentous injuries)
cervical stenosis
congenital odontoid hypoplasia
os odontoideum
Klippel-Feil anomalies

Answer 272

A

Force remains constant through range of motion:improves motor performance(eg.Biceps curls using free weights)
Constant muscle length and tension that is proportional to the external load; Causes muscle hypertrophy(eg. Pushing against an immovable object)
Shortened muscle and tension that is proportional to the external load;(eg.Biceps curl with elbow flexing)
Force remains constant as muscle lengthens;Most efficient method of strengthening muscle(eg.Biceps curl extending elbow)
Muscle contracts at a constant velocity through varied resistance(eg. requires special equip to test)
Rapid eccentric-concentric shortening.
Good training for sports that require power(eg. box jumps)
Distal end of extremity moves freely(eg.Seated leg ext)
Distal end of extremity fixed (eg. squats)

Answer 273

A

ATP-CP
Type II (A, B) - fast twitch
(note: IIA: aerobic and anaerobic IIB: primarily anaerobic)
10 seconds of high intensity

Answer 274

A

Oxidative phosphorylation (Kreb Cycle)
Type I muscle - slow twitch
endurance
High yield ATP and O2

Answer 275

A

Women have:

a higher body fat %
lower maximal oxygen consumption and hemoglobin
lower cardiac output
decreased muscle mass and strength

Woman have increased incidence of
◾patellofemoral disorders
◾stress fractures
◾ACL injuries

Answer 276

A

2-10x greater
(i) landing biomechanics and neuromuscular control differences ◾conditioning and strength play the biggest role ◾females land with their knees in more extension and valgus due to hip internal rotation
(ii) smaller notches
(iii) smaller ACL size
(iv) cyclic hormonal levels ( greater risk during preovulatory phase of the menstrual cycle
(v) leg alignment
(vi) genetic predisposition (underrepresentation of CC genotype of a COL5A1 gene sequence in females with ACL ruptures)

Answer 277

A

amenorrhea
disordered eating
◾insufficient caloric intake ◾is the most common cause of amenorrhea in female athletes
Osteoporosis
◾obtain a DEXA scan in female athletes with a history of amenorrhea and stress fractures

Answer 278

A

energy imbalance, low body fat, and hypothalamic-pituitary axis changes

Cessation of menses for 6 months after at least one normal cycle) is often caused by hormonal disturbances
50%
Bone demineralization and stress fractures

Answer 279

A

Not yet completed

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Knee and sport Flashcards

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