Sports Medicine Boards 2015

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Sports Medicine Boards 2015
2015-07-10 20:52:34
Sports Medicine Orthopaedics

Orthopaedic Injuries, fractures and fracture care and MSK PE terms
Show Answers:

  1. What is a Colles' Fracture?
    Extra-articular fractures of the distal radius that occur as the result of a FOSH (distal radial metaphyseal region with dorsal angulation and impaction, but without involvement of the articular surface)

  2. Best treatment for a Colles' Fracture?
    Short arm cast in with wrist is in the neutral position OR

    Long arm cast, with wrist in slight flexion and ulnar deviation, the forearm in a neutral position, and the elbow at 90 degrees.
  3. Difference between a Colles' and Smith's Fracture?
    Colles':  FOSH, distal fracture segment displaces distally

    • Smith's:  (aka Reverse Colles') Fall onto dorsum of hand/wrist; distal fragment displaces volarly
  4. What is a Segond fracture?
    A vertical avulsion fracture of the lateral tibial condyle (lateral capsular ligament attachment)

    • Frequently associated with ACL tear
  5. What is Froment sign?
    Seen in Ulnar Neuropathy: 

    FPL recruitment (Thumb IP Flexion) compensates for weakness of the thumb–index finger pinch (pinch grip) usually performed by the deep head of the flexor pollicis brevis and the adductor pollicis.

  6. What is a clay shoveler’s fracture?
    Avulsion fracture of the seventh cervical vertebra posterior spinous process

    • The shear force of the muscles (trapezius and rhomboid muscles) pulling on the spine at the base of the neck actually tears off the bone of the spine.
  7. What is a flexion teardrop fracture?

    Stable or Unstable Fracture?
    • Vertical axial compression and spine flexion cause a fracture of the anteroinferior aspect of the vertebra. 
    • Disruption of the posterior ligamentous complex, fragment displaced anteriorly, anterior ligamentous disruption: 
    • 3 columns = unstable
  8. What is a hangman fracture? Stable or Unstable?
    Hyperextension injury--fractures both pedicles of C2.  Spondylolisthesis of C2 on 3 is common

    • Unstable fracture but is rarely associated with injury to the spine.
  9. What is a posterior neural arch fracture? Mechanism of injury?  Stable or Unstable?
    Fracture in the (weak) posterior arch of C1; head hyperextended and the posterior neural arch of C1 is compressed between occiput and strong, prominent spinous process of C2.

    • Stable fracture as the anterior arch of C1 and transverse ligament are spared.
  10. What is a Boxer's Fracture?
    • Distal 5th metacarpal fracture.  Force of impact breaks neck of bone and causes it to angulate volarly and the shaft to angulate dorsally--creating a dorsal bump--loss of 5th knuckle
  11. What type of cast/splint is appropriate for a boxer's fracture?
    Burkhalter-type or Gutter splint
  12. Ottawa Ankle Rules (for Ankle radiographs)
    Bony tenderness at the posterior edge of the distal 6 cm AND

    Inability to weightbear 4 or more steps
  13. What intrinsic factors can contribute to Iliotibial band syndrome (ITBS)?
    Ankle pronation (forefoot varus, pes planus, tibial torsion, and metatarsus adductus)
  14. What is the primary restraint to ANTERIOR TRANSLATION of the tibia (with respect to the femur)?
    The ACL

    Two bundles of the ACL—the anteromedial and the posterolateral, named according to where the bundles insert into the tibial plateau
  15. Distinguishing stress fracture(s) from Medial Tibial Stress Syndrome (MTSS)
    Stress fractures--focal point tenderness

    MTSS (aka shin splints)--diffuse tenderness
  16. Suspected etiology of Medial Tibial Stress Syndrome (MTSS)
    Excessive stress at the fascial insertion of the flexor digitorum longus or medial soleus muscles. 

    Heel cord stretching may prevent MTSS
  17. Tibial Stress Fracture; High risk vs. Low risk fracture; difference?
    • High-risk fracture - Anterior tibia (Tension-side)
    • "Dreaded black line"
    • Non-union & recurrence high
    • NWB initially; cast vs pneumatic brace
    • 6-12 months; may require bone graft vs intra-medullary nailing (faster RTP)

    • Low Risk Fracture - Posteromedial (Compression-side)
    • Most common stress fxc site in athletes
    • Relative rest, NSAIDs, Correct training/technique errors
    • RTP as symptoms allow usu 2-6 weeks
  18. Subclavian Artery Compression:  Signs & Symptoms (in a throwing athletes)
    • Fatigue and weakness in his throwing arm
    • Symptoms worsening slowly
    • Increase with increasing work/pitch counts
    • Improves with rest
    • Sensation normal
    • Perceived temperature decrease with increased work/pitch counts
  19. Difference between Thoracic Outlet Syndrome (TOS) and Subclavian Artery Compression
    • TOS:  Implies neurological source (brachial plexus)
    • Subclavian A. Compression:  "Vascular" TOS and typically occurs in the vessel as it courses from the thorax into the upper limb
  20. What is The Roos stress test?  What condition does it test for?
    • Tests for Subclavian Artery Compression
    • Shoulders of the patient are held in abduction and external rotation of 90 degrees, and the patient must continue to maintain elbow flexion at 90 degrees. For several minutes, the patient must open and close his/her hands repeatedly.
  21. Patellofemoral Tendinitis is a clinical diagnosis, however some subtle imaging findings are suggestive.  Name two.
    • Tractional osteophyte in proximal patellar tendon
    • Osteopenia at the distal pole of the patella
  22. What is a Maisonneuve fracture?  Mechanism of injury?  Other associated injuries/fractures include?
    • A proximal fibula fracture (Maisonneuve)
    • Typically the result of an eversion injury
    • Inherently unstable
    • Often leads to an injury of the medial ankle ligament, tear of the distal tibiofibular syndesmosis and the interosseous membrane
  23. Best radiographic view to assess for the presence of widening between the fibula and talus
    • Mortise view
    • A standard anteroposterior (AP) view will reveal overlap between the talus and fibula making it difficult to evaluate for mortise widening
  24. What is the Risser Classification?  What condition is it typically used for?
    • An objective measure of growth--takes into account the closure of the iliac apophysis.
    • The iliac apophysis can be observed as a radiolucent line across the iliac crest on a pelvic AP view, developing early in adolescence
    • This apophysis fuses from the lateral to medial direction
    • Used for assessing scoliosis in adolescents
    • Risser 0: lack of observed fusion
    • Risser 1: fusion of the lateral 25%
    • Risser 2: up to 50%
    • Risser 3: up to 75%
    • Risser 4: up to 100%
    • Risser 5: complete fusion
  25. Scoliosis in adolescents rarely requires more than observation.  When is a more involved work up necessary?
    • Less than 8 years old should undergo MRI
    • Rapidly progressive curve (more than 1 degree per month)
    • Pain
    • Neurologic deficit
    • Unusual curve pattern (eg, left thoracic curve)
  26. Dextro vs Levo Scoliosis:  Which curve is more common in the Thoracic Spine?  Why does the less common type warrant an MRI?
    • Dextroscoliosis is much more common
    • The rare occurrence of levoscoliosis indicates a higher probability that the scoliosis may be secondary to a spinal cord tumor --> MRI
  27. What is the most common nerve injury associated with shoulder (gleno-humeral) dislocations?
    A) Musculocutaneous nerve
    B) Long thoracic nerve
    C) Radial nerve
    D) Axillary nerve
    E) Suprascapular nerve
    D) Axillary nerve
    (this multiple choice question has been scrambled)
  28. Which age group is more likely to injury the upper limbs?  Preteen or Teenagers?
    • Preteens commonly experience simple fractures, contusions, strains, and other injuries in the upper limbs
    • Teenagers more commonly experience knee injuries and other injuries to the lower limbs
  29. Characteristic of osteitis pubis?  Best radiographic view?
    • Unstable pubic symphysis is characteristic of osteitis pubis
    • Suggested when the symphysis widens to more than 7 mm or when the top surfaces of the superior pubic rami move more than 2 mm
    • Optimal Image:  Flamingo View (AP with alternating, unilateral, lower-extremity weight bearing 0
  30. Type 2 vs 3 apophyseal fracture of the tibia.
    • Type 2:  The inferior pole of the patella
    • Type 3:  The anterior tibial epiphysis
    • Active terminal extension is not possible in type 2 and 3 fractures due to the total disruption of the tubercle/patellar anchor
  31. Which joint is disrupted during a Lisfranc injury?
    A) Inter-phalangeal joint
    B) Tarsal-metatarsal (T-MT) joint
    C) Metatarsal-phalangeal joint
    D) Tarsal-navicular joint
    B) Tarsal-metatarsal (T-MT) joint

    if it goes unrecognized can produce pain and such an injury may be debilitating. Recognizing this injury early is important. Often times, comparison anterior-posterior oblique and weight-bearing views can help
    identify this type of injuries.
    (this multiple choice question has been scrambled)
  32. Nonunion is a common complication among patients with a scaphoid fracture. What
    order of fracture (from most likely to least likely) represents the correct risk for nonunion?
    A) Distal pole, waist, proximal pole
    B) Waist, proximal pole, distal pole
    C) Proximal pole, distal pole, waist
    D) Waist, distal pole, proximal pole
    E) Proximal pole, waist, distal pole
    E) Proximal pole, waist, distal pole

    The scaphoid bone’s blood supply only enters at one end (distal). This results in a high rate of malunion and nonunion, and patients with a scaphoid fracture are more susceptible to avascular necrosis.  Healing times are longest in patients with more proximal fractures.  A high index of suspicion isneeded because scaphoid fractures do not always appear in initial plain x-rays.
    (this multiple choice question has been scrambled)
  33. What structure is the primary static stabilizer for avoiding lateral subluxation of the patella?

    A) medial patellofemoral ligament
    B) vastus medialis obliquus (VMO)
    C) medial patellotibial ligament
    D) superficial oblique retinaculum
    A) medial patellofemoral ligament

    At 20 degrees of flexion, the patellomeniscal ligament and lateral retinaculum contribute 13% and 10%, respectively, of total restraining force, while the patellofemoral ligament contributes 60% of total
    restraining force.
    (this multiple choice question has been scrambled)
  34. Imaging criteria for a syndesmosis injury
    • Syndesmosis injury is confirmed by less than 10 mm of tibiofibular overlap or more than 5mm of clear space
    • Results on anterior drawer and talar tilt tests negative
    • Squeeze test and external rotation will cause pain

  35. What is Sever disease?
    • aka calcaneal apophysitis
    • thought to occur secondary to the strong vertical shear forces along the apophysis prior to fusion being complete.
    • Apophysis may appear at 7 to 9 years of age, fusion occurs around 17 years of age, and the mean age for presentation is 10 to 12 years of age
    • Skeletal maturity would not be seen in a patient with suspected Sever disease.
  36. What is the "clunk" test used to evaluate for?
    • For possible mild glenohumeral instability and labral defects
    • Pt placed in a supine position and his or her arm is put in full overhead abduction. The doc places hands posterior to the humeral head to apply anterior pressure while placing the other hand at the level of the humeral condyles to provide axial loading and rotation.
    • A "clunk" or grinding may indicate a labral tear or a Bankart lesion caused by instability.
  37. An 11-year-old girl immediately presents to you after she began to experience tenderness and pain deep within her hip across the medial and proximal femur. She says that she was participating in a long jump when she was injured and fell in the sandpit. She denies any prior hip problems. Upon examination, she feels pain with passive external and internal rotation of her hip and with active hip flexion.  The rest of the examination is unremarkable.
    You diagnose avulsion of the apophysis over which of the following?

    a) Ischial tuberosity
    b) Anterior superior ischial spine
    c) Anterior inferior ischial spine
    d) Lesser trochanter
    e) Greater trochanter
    • d) Lesser trochanter
    • Avulsion fractures of an apophysis near the hip
    • Iliac crest (abdominal muscles)
    • Ischium (hamstrings)
    • ASIS (sartorius)
    • AIIS (abdominal rectus)
    • Lesser trochanter (iliopsoas)
  38. A 19-year-old girl presents to you with a hyperextension injury to the PIP joint of her middle finger. She says that she was playing basketball and, when the injury happened, she was trying to deflect a pass. Her finger became dorsally dislocated, but the sideline physician at the game was able to reduce the dislocation. Following the game, you decide to obtain x-rays, which are negative for bony injury. They also reveal good alignment.
    What is the next most appropriate step in the management of this patient's condition?

    A) The finger should be splinted in 20-30 degrees of flexion
    B) No further treatment is necessary
    C) The finger should be splinted in full extension
    D) The hand and finger should be placed in a short arm cast
    A) The finger should be splinted in 20-30 degrees of flexion

    Volar plate rupture is very likely after a hyperextension injury, her finger must be splinted in 20-30 degrees of flexion. Doing so will help heal the volar plate.
    Splinting in extension would be appropriate if there were a volar dislocation at the PIP, but this is not the case in this scenario.
    Short-arm casting is not appropriate for a PIP dislocation.
    (this multiple choice question has been scrambled)
  39. A 20-year-old basketball player presents to you after he fell on his pronated right hand. He says that he treated by his athletic trainer during the game. The trainer noted that the player had prominence of the ulnar head and supination loss, which he reduced with supination of the forearm.  During his visit to your office, the player has full range of motion. You perform a neurovascular examination, which is intact. You order x-rays, which come back with no evidence of dislocation, fracture, or distal radioulnar joint (DRUJ) widening.
    How should you treat this patient's injury?

    A) Ulnar gutter splint
    B) Long arm cast for 6 weeks
    C) Thumb spica splint for 2 weeks
    D) Short arm cast for 4 weeks
    B) Long arm cast for 6 weeks

    An example of an uncomplicated dorsal dislocation of the DRUJ. His athletic trainer successfully reduced it by volarly moving the ulnar head. The normal results on the neurovascular examination and the lacking evidence of a fracture or subluxation/dislocation suggest that this patient can be conservatively treated.

    Conservative treatment includes a long arm cast (including the elbow) that he will have to wear for 4-6 weeks.

    The other options would not prevent supination/pronation of the forearm or optimally protect the DRUJ.
    (this multiple choice question has been scrambled)
  40. A 14-year-old girl presents to you. She is a soccer player and she recently sustained a groin strain during a game. At the time that the strain occurred, she was performing a sliding tackle. Her examination is remarkable for an avulsion of the lesser trochanter with 1 cm displacement. What is the most appropriate management for this patient's

    A) Start physical therapy
    B) Refer immediately for surgical management
    C) Tell her to rest for 1 week and then clear her for a return to sports when her pain has resolved.
    D) Place her on crutches and make her nonweight bearing.
    D) Place her on crutches and make her nonweight bearing.

    Avulsions at the lesser trochanter (the insertion of the iliopsoas muscle) can be managed with nonweight bearing with crutches, with the patient progressing weight bearing as tolerated. As the patient's pain improves, the health care professional should begin therapy aimed at improving range of motion, and adding stretching and strengthening exercises.
    Patients with this type of injury can typically return to sports in 2-4 months.
    Avulsions with displacement of more than 1 cm should be referred for open fixation and reduction.
    (this multiple choice question has been scrambled)
  41. A 15-year-old rugby player presents to you. She injured her left fourth finger and is unable to flex the DIP. Fullness is present along the flexor tendon.
    What is the most appropriate course of treatment for this patient?

    A) NSAIDs and ice
    B) Custom splint during games
    C) Early surgical intervention
    D) Buddy taping to left third finger
    C) Early surgical intervention
    (this multiple choice question has been scrambled)
  42. Compare/Contrast Jersey and Mallet finger
    Mechanism of injury and treatments.
    • Jersey Finger:
    • Avulsion of the flexor digitorum profundus (FDP) tendon
    • Cannot flex DIP joint; usu the 4th digit
    • Mechanism: Usually hyperextending the DIP joint when attempting to flex
    • Tx:  Surgery

    • Mallet finger: 
    • A flexion deformity of the DIP joint presents as an inability to extend the DIP joint.
    • Mechanism:  Sudden forceful flexion of the DIP joint causes this type of deformity
    • Tx:  Non-operatively managed (splinting in complete extension for 6-8 weeks).  Surgery is only necessary with large fractures of the distal phalanx.
  43. What type of Salter-Harris fracture poses the greatest risk to joint integrity in children?
    a) Type I
    b) Type II
    c) Type III
    d) Type IV
    e) Type V
    • c) Type III
    • Mneumonic SALTR:
    • Type I-Slipped physis
    • Type II-Above the physis, into the metaphysis
    • Type III-Lower than the physis (epiphysis)
    • Type IV-Through the physis, metaphysis and epiphysis
    • Type V-Rammed physis
  44. What is a Stener lesion?  What injury is it associated with? Frequency? Treatment?
    • Stener Lesion: Associated with Gamekeeper's Thumb.  The ulnar collateral ligament (UCL) at the first metacarpophalangeal joint is torn and is abnormally folded superficial to the adductor aponeurosis. The interposition of the thumb extensor mechanism between the torn fragments of the UCL prevent the spontaneous healing of the ligament.
    • Frequency:  29%
    • Treatment:  Surgery
  45. What is a Bankart lesion?  What structure is affected?  Treatment?
    • Avulsion of the anterior capsulolabral complex of the shoulder
    • Treatment:  Surgery (typically)
  46. Is there a difference between a Bankart Lesion and a Bony Bankart?
    Bankart Lesion:  Labral tear WITHOUT bony involvement.  Tearing may involve the periosteum

    Bony Bankart:  Bankart with bony fragment/glenoid fracture

  47. What is a Hill-Sachs Lesion?
    • A bony defect in the posterolateral portion of the humeral head
    • Associated with a history of shoulder dislocations (primary dislocation)
    • Most commonly seen on MRI
    • PE = Anterior apprehension sign and tenderness across the posterior aspect
  48. Which statement is true of female landing mechanics that may predispose them to non-contact ACL injuries?
    A. Females land with decreased anterior tibial translatory force
    B. Females land with decreased hip external rotation and abduction
    C. Females land with increased knee and hip flexion
    D. Females land with a decreased quad to HS ratio
    B. Females land with decreased hip external rotation and abduction
    (this multiple choice question has been scrambled)
  49. All of the following are features of tendinosis except:
    A.  Reduced proteoglycan matrix
    B.  Immature collagen cross-linking
    C.  Increased tendon diameter
    D.  Increased vascularity
    A.  Reduced proteoglycan matrix
    (this multiple choice question has been scrambled)
  50. Following traumatic anterior instability of the shoulder, which is the greatest predictor of recurrence?
    A.  Age
    B.  Mechanism of dislocation
    C.  Associated nerve injury
    D.  Status of rotator cuff
    A.  Age
    (this multiple choice question has been scrambled)
  51. What lesion(s) is/are frequently associated with traumatic anterior (antero-inferior) instability of the shoulder?  What ligament(s) is/are commonly injured with this type of instability?
    • Lesions: 
    • >90% have a Bankart Lesion (avulsion of the capsulolabral complex of the shoulder)
    • Associated with an Axillary Nerve Injury (7%)

    Ligament injured:  Anterior band of the IGHL (inferior glenohumeral lig)
  52. What is the rotator interval?  Borders? Contents?
    • The rotator interval describes the anatomic space bounded by the subscapularis, supraspinatus, and coracoid.
    • Contains coracohumeral and superior glenohumeral ligament, the biceps tendon, and anterior joint capsule.
  53. Difference between Kohler's Disease and Kienböck's Disease?
    • Kohler's:  "Think of Dr. Kohls aka Dr. Scholl's = feet Osteonecrosis Navicular of the FOOT
    • Kienböck's:  Osteonecrosis Lunate in the HAND
  54. 11 yo premenarchal female soccer player presents to clinic c/o gradual onset heel pain.  The heel pain is bilateral.  She recently played in a soccer tournament over the weekend (5 games) and also ran a 5K as a fundraiser.  Now reporting an intermittent limp.  Most likely diagnosis for her heel pain is: 
    A.  Aneurysmal bone cyst of the calcaneous
    B.  Retrocalcaneal bursitis
    C.  Calcaneal apophysitis
    D.  Calcaneal stress fracture
    E.  Achilles tendinitis
    C.  Calcaneal apophysitis
    (this multiple choice question has been scrambled)
  55. What is the most common type of injury in children?
    • Apophysitis/Epiphysitis
    • Secondary to repetitive stress on ossification centers or overuse injuries with traction/compression to epiphysis or apophysis
    • Classic age:  8-16
    • Analogous to a stress fxc in an adult REMEMBER injury occurs at weakest link which is the epiphysis or apophysis in children
  56. Difference between the Apophysis and the Epiphysis (and Apophysitis and Epiphysitis)
    • Apophysis:
    • Where the musculotendinous unit inserts
    • Vulnerable to traction injuries (Apophysitis) as muscle and tendon growth may be slow relative to bone growth.
    • Epiphysis: 
    • The actual site of bony growth (growth plate)
    • Inherently unstable and vulnerable to shear forces which can damage bone structure (Epiphysitis) through slips or fractures (e.g. SCPE)
  57. A "high ankle sprain" represents injury to which of the following structures?
    a)  Anterior talofibular ligament
    b)  Calcaneofibular ligament
    c)  Anterior Inferior Tibiofibular ligament
    d)  Posterior Talofibular ligament
    • c)  Anterior Inferior Tibiofibular ligament
  58. Abnormal criteria for Atlanto-Odontoid distance on X-rays?
    • >3-4 mm
    • Down's Syndrome (10-20%) associated with AA instability; only 1-2% symptomatic
  59. What is Klippel-Feil Syndrome?  Any contraindication with participation in sports?
    • Congenital fusion (synostosis) of any 2 of the 7 cervical vertebrae
    • Restricted from contact/collision sports if Type 2 (multiple fused non-adjacent) or Type 3 (multiple adjacent) above C3
  60. Biomechanical, Anatomical, Neuromuscular and Hormonal gender differences responsible for F>>M ACL rupture statistics
    • Female have/exhibit
    • Decreased hip/knee flexion upon landing
    • Increased valgus angle
    • Increased femur internal rotation
    • Increased activation of Quads (vs. Hamstrings/Gluts)
    • Smaller notch width
    • Smaller ACLs
    • Smaller lateral articular surface & increased posterior tibial slope
    • Greater A-P laxity
    • Inc risk of rupture during ovulation (high estradiol)
    • Inc risk of rupture during follicular phase (low estradiol)
  61. What is a Bennett Lesion?  What is a Bennett Fracture?
    • Bennett Lesion: A mineralization of the posterior band of the inferior glenohumeral ligament as a result of extra-articular posterior capsular avulsion injury (blue arrow)

    • Bennett Fracture/Dislocation: 
    • Two piece fracture dislocation of the base of the thumb
    • Intra-articular (thus requires ORIF)
    • Dorsolateral dislocation
    • Small fragment of 1st metacarpal continues to articulate with trapezium
    • Lateral retraction of first metacarpal shaft by abductor pollicis longus
  62. SLAP vs Bennett vs Buford vs Hill-Sachs vs Bankart vs Reserve Bankart
  63. Myositis Ossificans occurs in which muscle(s) most commonly?
    • Vastus Intermedius
    • Brachialis
    • Heterotopic bone formation occurring in the periphery of a muscle hematoma
    • Incidence 9-17%; most common age 10-30
    • Quad Contusions treated with wrapping lower limb in deep knee flexion for 24 hours; may require aspiration if hematoma is large and/or uncomfortable
  64. What is a Paratenon?  Give an example and contrast to a synovial sheath
    • Achilles Tendon = Paratenon
    • Outer layer of ALVEOLAR tissue to reduce friction with underlying epitenon
    • Synovial Sheath - 2 thin layers with lubricating fluid between them to allow gliding between fibrous sheath & tendon