High Yield Review:

Upper Extremity
Bashir A. Zikria, MD
Johns Hopkins Department of Orthopaedics

Glenohumeral Ligaments

• SGHL
• Inferior instability in adducted arm
• Rotator Interval
• CHL
• Inferior instability in adducted arm
• Rotator Interval
• Rotator interval
• Inferior instability in adducted arm
• Test by ER of arm at side - decrease
 Glenohumeral Ligaments

• MGHL
• Limits anterior instability in ER and abducted to 45°

O’Brien SJ, Neves MC, Arnoczky SP, et al: The anatomy and histology of the inferior glenohumeral
ligament complex of the shoulder. Am J Sports Med 1990;18[5]:449-456.)
Am J Sports Med November 2000 vol. 28 no. 6 910-917

Glenohumeral Ligaments

• IGHL
• Major stabilizer of arm when ER and abducted between 45° to
90°
• Limits anterior and posterior translation

Am J Sports Med November 2000 vol. 28 no. 6 910-917

Anterior Instability

• Patients AGE is the most important factor for recurrence

and Trauma (contact sports)
• Bankart Lesion
• HAGL
• IGHL is main restraint to anterior in abduction and
external rotation

Anterior Instability

•< 25 years of age, the recurrence

rate is between 55-95 %
•Axillary nerve
•>40 years of age, the recurrence rate
is much lower, but higher incidence of
rotator cuff injury
Anterior Instability

• Bone defects – chronic

dislocations : if greater
than 30%, may need
bone graft or laterjet
type procedure
• Latarjet
• Coracoid
• Soft tissue sling

Anterior Instability
• Trial of non-operative for 1st time dislocation
• Arthroscopic or open
• Same for test
• Slightly better ROM - arthroscopic
• OPEN – Subscap tears
• recognize bone defects >25-30%; Engaging Hill Sachs
Posterior Instability

• Blocking in football (Lineman)

• Seizures
• Electric Shock
• Missed dislocation
• Arm in adduction and internal rotation
• Always need axillary view
• Primary stabilizers posteriorly:
• Posterior IGHL
• JERK Test
• Kim Test
• Non operative – first

Escobedo et al.
AJR 2007; 188:193-197
Am J Sports Med April 2011 vol. 39 no. 4 874-886

Multidirectional Instability
• Atraumatic
• Patulous capsule
• Swimmers
• Exhaustive conservative treatment (6-12 months)
• Arthroscopic plication or Inferior capsular shift
• Rotator Interval
• Indicated in MDI
• Persistent inferior or inf-anterior translation
Internal Impingement

• Late cocking/early acceleration phase of throwing

• GIRD > 20 degrees
• Most treated non operatively
• Posterior capsule stretching, rotator cuff strengthening, and
changing mechanics of throwing
• Operative – repair lesion (SLAP) and debridement

ARTICULAR Sided
Partial Rotator
Cuff Tear

SLAP Issues

SLAP TEARS
• Obrien’s Test
• Nonoperative : FIRST
• RTC strengthening to
stabilize shoulder
• Scap stabilizers
• Surgical
• Type II repair with suture
anchor
• Internal Impingement
• Partial articular side rtc
• debride
Suprascapular nerve
and spinoglenoid cyst
• Volleyball players
• Cysts associated with SLAP
• Traction injury
• CTQ: 2 locations
• Spinoglenoid notch
• IS only
• Suprascapular notch
• Affects both SS and IS
Biceps Pathology

• Anterior Shoulder
• NON OPERATIVE
• No evidence to support tenodesis vs. tenotomy
• Cosmetic
• Sub Pectoral
• Musculotaneous

Rotator Cuff – Key Points

ACUTE
• Lack atrophy
• Surgical indication: repair
early for exam purposes
CHRONIC
• Often atraumatic with
insidious onset
• Muscle atrophy
• Generally begin with
Physical Therapy
• Massive tears
• Preserve CA ligament and
arch
Rotator Cuff – Key Points

ADVANTAGES OF
ARTHROSCOPIC PARTIAL ROTATOR CUFF TEARS
• No deltoid detachment • Foot print 12 mm
• Intra-articular pathology • Articular sided
• Less soft tissue disection • > 6 mm
• Internal Impingement
• Less pain and blood loss
• Bursal sided
• > 3 mm

AC Joint Anatomy

• AC Ligaments
• Anterior – posterior stability
• Posterior and superior contribute most to horizontal

• CC Ligaments
• Provide vertical stability to AC joint
• Two components:
• Trapezoid – 2.5 cm
• anterolateral
• CTQ: Conoid – 4.5 cm
• STRONGER
• Posteromedial
AC Separations - Treatment

• CTQ: TYPES I and II

• Always nonoperative
• Long term sequelae
• Osteoarthritis
• nearly 50% of patients
• CTQ: Type III
• Trial NONOPERATIVE
• Long term sequelae
• Weakness in Benchpress
• Operative
• Overhead athletes and laborers

Distal Clavicle Fractures

• Similar to AC Joint
• 3 Types
• Type I - distal to ligament
• Always nonoperative
• CTQ: IIA and IIB – Prone to malunion and nonunion
• Initially treat nonoperative – essentially treat like Type III AC Joint
Separation
Sternoclavicular Dislocations

• Posterior sternoclavicular ligament/capsule –

primary stabilizer of SC Joint
• Costaclavicular ligament – extracapsular and
strongest ligament in preventing superior
translation of medial clavicle
• IVDA – septic

Treatment of Sternoclavicular
Dislocations

ANTERIOR
• Non-operative treatment
• Closed reduction often not
successful
POSTERIOR
• Associated neurovascular
• Consider CT to rule out
mediastinal compression
• Thoracic surgeon
Brachial Plexus Anatomy

• Long Thoracic – Serratus anterior and medial

winging
• Spinal Accesory – Trapezius and lateral winging
• Suprascapular – Suprascapular notch (SS and IS)
and spinoglenoid (IS)

Netter FH: Atlas of Human Anatomy, ed 2. Teterboro, NJ, ICON Learning Systems, 1997

Axillary artery - 3 parts in relation to

the pec minor
• Part 1 Medial to Pec Minor
• Supreme Thoracic
• Part 2 Deep to Pec Minor
• Thoracoacromial
• Acromial
• Deltoid
• Pectoral
• Clavicular
• Lateral Thoracic

Gray's Anatomy: The Anatomical Basis of Clinical Practice, 40th edition

(2008), 1,576 pages, Churchill-Livingstone, Elsevier
Axillary artery - 3 parts in relation to
the pec minor
• Part 3 - Inferior to pec minor
• Subscapular
• Thoracodorsal
• Circumflex scapular
• Anterior humeral circumflex
• Posterior humeral circumflex
– Quadralateral space w/
axillary nerve
• Posterior inferior humeral
head

Adhesive Capsulitis

• Women more common

• Know associated risk factors:
• DM
• Thyroid
• Decreased PROM and AROM
• Treatment
• Nonoperative – PT
• Operative
• When at least 3 – 4 months of conservative measures fail
• Arthroscopic capsular release and MUA
 Elbow Anatomy

Medial
• UCL
• Anterior bundle
Late cocking phase
Lateral
• Lateral ulnar collateral ligament
• Posterolateral rotatory instability
• Most common pattern
• Radial Head
• Secondary stabilizer to valgus

Kvitne RS, Jobe FW: Ligamentous and posterior

compartment injuries, in Jobe FW
[ed]: Techniques in Upper Extremity Sports Injuries.
Philadelphia: Mosby-Year Book,
1996, p 412

Elbow motion and dislocation

Motion Function Range DISLOCATION

• Congruent reduction
Extension 30
• Early range of motion
Flexion 130
• surgical repair rarely:
Pronation 50 • Unstable arc of motion
Supination 50 from 60 to full flexion
• Significant fracture
• Incongruent reduction
• Most common complication
• Loss of terminal extension

O’Driscoll et al: Elbow subluxation and dislocation: A spectrum of

instability. Clin Orthop 1992;280:186-197
Elbow Arthroscopy - Indications

• Diagnostic
• Lateral Epicondylitis
• UCL reconstruction - diagnosis
• Articular cartilage pathology
• OCD
• Debridement of osteophytes
• Removal of loose bodies
• Intraarticular fractures
• Synovitis

Elbow Arthroscopy - Risks

• CTQ: Direct lateral
• Lateral antebrachial
cutaneous
• CTQ: Anteromedial
• Medial antebrachial
cutaneous
• Median nerve
• Brachial artery
• CTQ: Anterolateral
• Radial nerve
• NO POSTEROMEDIAL PORTAL
• Ulnar nerve
Osteochondritis
Dessicans (OCD)
• Nonsurgical -
• Avoid activity
• Rest
• Surgical Indications
• MECHANICAL OR UNSTABLE
• Loose bodies
• Intra-articular cartilage
instability

J Am Acad Orthop Surg July/August 2004 vol. 12 no. 4

246-254

Medial Epicondyle

AVULSION APOPHYSITIS
• TEST – NONOP unless • medial pain in cocking
• Surgical Indications: • early or late apophyseal
• Incarcerated fragment closure
• Valgus instability • Nonoperative
• No clear consensus exists as
to the absolute amount of
acceptable displacement
Posterior Elbow

IMPINGEMENT STRESS FX
• Late Acceleration and • Triceps tensile overload
follow through – posterior • transverse pattern
pain
• Nonoperative
• Posteromedial spur • restriction of 6 to 8 weeks
olecranon – valgus
extension overload test • SCREW FIXATION
• Non operative
• Fail conserve
• Removal of spur 3-5mm

Tendon injuries in the Elbow

DISTAL BICEPS TRICEPS

• Failure to repair the distal • Weakness in extension
biceps tendon will result in loss
of 40% supination strength and • Weight lifters – anabolic
10% loss in flexion strength steroids
• Surgical • Surgical repair
• ONE INCISION • Anchors
• Lateral antebrachial • Bone tunnels
cutaneous
• Two incision technique
• HO can be a
complication
• Rehab – passive range of
motion
• Supination
• Flexion
Olecranon Bursitis - Wrestlers
• Aseptic
• Nonoperative
• Self limiting, and no medical
treatment is needed.
• Aspiration
• Chronic and recurrent
• Surgical consideration
• Septic
• Skin temperature
• Aspiration
• Staphylococcus aureus or
Staphylococcus epidermidis
• Main causative agents
(Staph 90 percent)
• Empiric Antibiotic
• Surgical
• Complication
• Skin

QUESTIONS
 Anikar Chhabra, MD MS
Director of Orthopedic Sports Medicine
Mayo Clinic Arizona
Banner Good Samaritan Ortho Residency and Fellowship
Head Team Orthopedic Surgeon: Arizona State University

Consultant and Speaker: Arthrex, Inc

Consultant: RTI Biologics, Cayenne Medical

No conflict of interest regarding this talk

Warren R. The Lower Extremity and Spine in sports Medicine

 Joint Line Tenderness 
 SENSITIVITY 85% 
 SPECIFICITY 30%
 McMurrays
 SENSITIVITY 29%
 SPECIFICITY 96% 
 Apleys
 SENSITIVITY 16% 
 SPECIFICITY 80%
 Thessaly Test
 SENSIVITY 90%
 SPECIFICITY 96%
Fowler and Lubliner, 1989
Karacholios et al, 2005
 Longitudinal (Vertical) Tear  
 Peripheral Third of Meniscus     
 Peripheral Detachment
 With ACL Reconstruction
 Acute Tear
 Less than 40 years old

Miller MD. Knee Surgery 1994

 Menisci 65 to 75% water
 Type I Collagen 
 Peripheral third vascular
 Lateral meniscus more biomechanical support
 Partial meniscectomy increases contact pressure
 50% go on to fairbanks changes
 Predict long term success following partial menisectomy
 age younger than 40
 normal alignment
 minimal arthritis
 single fragment tear
 Medial > Lateral tears Gold standard for meniscal
repairs: 
 Nerve Risks for medial   Inside Out
(Saphenous) and lateral 
Most common location of 
(Peroneal) meniscal repairs degenerative tears:
 Vertical mattress strongest  Posterior horn MM
 Ligamentous unstable  Meniscal cysts are associated 
knees decrease success  with what type of meniscal
tears:
rate of repair from:   Horizonatal LM
 70 to 95% to 30 to 70% Location of Popliteal cysts: 
 Med Head of Gastroc and 
SM

O’Connor JJ. Knee Ligaments, 
Structure, 
Function, Injury, and Repair
1. ACL Two Bundles
2. Middle Geniculate Artery
3. Regain Motion
4. ACL and Meniscus

1. Lateral – acute 
2. Posterior horn medial ‐ chronic
5. No difference in graft choice

6. Women with increased dynamic valgus and high 
abduction loads at increased risk for ACL Injury
7. Strength:
1. Hamstring > Patella tendon > Native ACL
8. Technical error most common complication
1. Anterior femoral tunnel
2. Anterior tibial tunnel
8. Rehab – closed chain
  2 Bundles named from fem→ b insert
 AL (tight in flexion)
 PM (tight in extension)
 Meniscofemoral Ligs:
 Humphry (anterior)
 Wrisberg (posterior)
 CTQ: Middle Geniculate A.

 Posterior drawer
 Aware of multiligament injury
 Indications for PCL reconstruction:
 Usually grade III isolated 
▪ Non operative
▪ Emphasis on quadriceps rehab
 Single bundle recreates Anterolateral bundle
 Transtibial vs. Tibial Inlay
 Tibial Inlay eliminates critical turn at the tibial
aperture of the tunnel
 Knee in full extension decreases force of PCL and 
reduces posterior sag 
 Chronic PCL – medial compartment and PF DJD
  Superficial:   Deep:
 Biceps, ITB  LCL, Popliteus, 
Poplietofibular
lig., Capsule, 
Arcuate

Seebacher JR. The structure of the 
posterolateral aspect of 
the knee. JBJS

CTQ
Injury Exam
PCL ↑ER at 90º
PLC ↑ER at 30 º
PCL/PLC ↑ER at 30 & 90 º
 30‐50% incidence vascular injury with anterior 
dislocation!
 Popliteal artery injury 10%‐65%
 Vasc exam before and  after reduction 
imperative
 If pulseless after reduction:
▪ arteriogram in OR ‐ repair / exfix
▪ Low threshold for fasciotomies
▪ Low threshold for primary collateral repairs
 If diminished after reduction:
▪ Stat angio
 If normal after reduction:
▪ Serial ABIs vs. angio

 MCL is primary stabilizer to valgus @ 30 deg; 

 LCL to varus @ 30 deg
 Popliteus complex is a primary stabilizer to external 
rotation @ 30 deg
 Varus/valgus laxity in full extension is an indicator of 
a combined ligament injury (cruciate + collateral)
 Neurovascular injuries common
 Bicruciate or multiligament injury involving 3 or 
more ligaments should be considered a 
spontaneously reduced knee dislocation.
 Pellegrini-
Stieda

SEGOND OCD

TIBIAL AVULSION
FX
Brinker MR. Fundamentals of Orthopaedics

Must Know:
 Fairbanks changes
 Segond lesion is an avulsion of what? What 
does it indicate?
 Bone bruise pattern for ACL injuries
 Stress radiographs for physeal injuries
  Normal Biomechanics 
 CTQ: Mechanical axis – center 
of femoral head to center of 
ankle
▪ Normal line: medial
 Anatomic axis
 Sagittal – just anterior to 
center of rotation
▪ Allows passive locking of 
knee in extension
Rohr WL. Operative Orthopaedics

 Indications
 physiologic age < 60 yrs in an athlete, laborer 
 less than 15 deg of fixed varus deformity 
 Goal: Overcorrection 5‐10 deg

Lateral closing wedge       Medial opening wedge        Dome osteotomy

Wright JM. High Tibial Osteotomy. JAAOS 2005
 Indications
 Valgus >12 degrees
 Stable joint with no evidence of 
subluxation
 ROM of at least 90 deg of flexion 
 Flexion contracture < 15 deg
 Contraindications
 Medial DJD or loss Medial meniscus
 Significant flexion contracture
 Decreased ROM 

 Goal: horizontal joint line

Wright JM. High Tibial Osteotomy. JAAOS 2005
  Leg length discrepancy < 2cm
▪ 5 to 7° of valgus and 15° of flexion 
 Leg length discrepancy 2cm to 4cm
▪ 5 to 7° of valgus and  knee in extension
 Leg length discrepancy > 4cm
▪ 5 to 7° of valgus and  consider graft or spacer to limit gait 
abnormalities

Radiographic eval.
 AP/ Lat 0.8 nl
 Insall‐Salvati
 Blackburne‐Peel
 Trochlear depth on lat 1.2 nl
 Merchant
 Trochlea (hypoplastic)
 Pat. Tilt
 OA
 CTQ: CT/MRI scan : TT/TG distance
 Normal <15
 Abnormal >20
 Patellar instability
 MRI
 Acute patellar disloc.
 CTQ: Bone Bruise pattern
 Pain / Normal alignment
 Risk Factors for PF pain
▪ Shortened quad muscle
▪ Abnl VMO muscle reflex response time
▪ Decreased explosive strength
▪ Hypermobile patella

 Pain / Abnormal alignment: 
 Patellar tilt/ lateral patellar compression
▪ McConnell taping
▪ Rehab‐ stretch lat. Retinac, strengthen quad/ VMO
▪ Lat. Release only if lat Retinac tight / no lat quad vector force
▪ Medial tibial tub. tx: Lat Quad vector and no chondrosis
▪ Anteromed tibial tub. Tx: Arthrosis in lat. facet

Miller MD. Review of Orthopaedics
 Know the P/F Biomechanics
 Treatment begins with nonoperative
management
 Most Common Surgical Indications
 Arthroscopic Removal of loose bodies
 Instability with no mal‐alignment: proximal 
realignment
 Instability & with mal‐alignment: proximal/distal 
realignment

 Patella Baja vs. Alta measurements
 Essential structure to repair with 
subluxing/dislocating patella: MPFL
 Superomedial patellar arthrosis is 
contraindication for bony distal realignment
Indications
 Localized, unipolar symptomatic 
chondral lesion of femoral condyle, 
trochlea, or patella 
 Moderate to high‐demand patient in 
whom joint replacement is poor 
option
 Moderate to large size cartilage 
lesion
 Size determines technique
 Pain and symptoms should 
correspond to the location of the 
cartilage lesion

Contra‐Indications
 Morbid obesity 
 Inflammatory and systemic arthritis
 Other medical problems, such as insulin‐
dependent diabetes, that may affect healing /  
incorporation of allograft tissue
Treatment
CTQ: Malalignment key!!!
 Soft Cartilage but intact w/o separation
 Retrograde drilling
 Soft Cartilage but intact w/ early 
separation
 Retrograde drilling + fixation
 Cartilage Partially detached
 Debride base, reduce + fixation

Treatment
CTQ: Malalignment key!!!
 Loose body/ Crater (NWB area)
 Debride and microfx
 Loose body/ Crater (WB area)
 Debride + microfx (<2cm) vs.
 OATS  vs.
 ACI (larger lesion)
 Osteotomy/ hemiarthroplasty (large)
 Most important prognostic factor for OCD 
lesions: Physis
 Most common locations of OCD 
 When is operative treatment indicated in OCD 
lesions
 Basic science of microfracture technique
 Recognize SONK following scope, treat 
conservatively initially

 “Wrong” answers:
 Indiscriminate ordering of MRI’s
 Steroid injections
 Thermal Shrinkage
 “Diagnostic” arthroscopy
 Initial operative treatment of PCL injuries
 Initial operative treatment of PF/overuse problems
  Labral tears Contraindications
 Cam – Femoral head (α‐
 Advanced OA
anlge >55°)
 <2mm of joint space
 Pincer – Acetabulum 
(cross‐over sign or CEA 
>40°)
 Chondral injuries
 Instability
 Snapping hip
 Ligamentum teres
injuries

 Portals
 Anterior
▪ Starting point – line from 
the tip of greater troch
intersecting with line 
from ASIS
▪ 45 degrees cephalad and 
30 degrees midline
▪ Working portal
▪ CTQ: Risks ‐ femoral 
artery, femoral nerve, 
lateral femoral 
cutaneous nerve, and 
lateral circumflex artery
Byrd JWT. Hip Arthroscopy: Principles and Application
 Portals
 Anterolateral
▪ 1st Established
▪ Superior anterior corner 
of greater trochanter
▪ Least risk to neurovascular 
structures – CTQ: Superior 
gluteal nerve

 Posterolateral
▪ 2 to 3 cm posterior to tip 
of GT
▪ Sciatic Nerve at risk
CTQ ▪ IR Leg to avoid Miller MD. Orthopaedic Surgical Approaches

Byrd JWT. Hip Arthroscopy: Principles and Application

CTQ: Two types
 Cam ‐ femoral based
 Aspherical head
 Reduced head neck offset
 young, active, males
 Cartilage injury at chondral‐labral 
junction
 Pincer –acetabular‐based
 over coverage or acetabular retroversion
 abnormal contact between acetabular  rim 
and femoral neck 
 Labral tears
 Middle‐aged women engaged in athletic 
activity

Peters CL. Treatment of Femoro‐Acetabular Impingement…JBJS
 Distinguish the 2 types of FAI: CAM and Pincer
 Structures at risk with arthroscopic portal 
placement:
 Anterolateral = Superior Gluteal nerve
 Anterior = Femoral artery and nerve, LFC nerve
 Posterolateral = Sciatic nerve
 Classic physical exam signs of impingement
 Labral tears associated with instability and 
pincer lesions

CTQ: Os Trigonum
 PF Impingement
 Pain with Passive Ankle Plantar Flexion
 Ballet (En Pointe)
 Surgical Excision (Lateral)

CTQ: Os Subfibulare
 Avulsion fracture ATFL
 May be associated with chronic ankle 
instability
  ATFL
 Most common
 CTQ: MOI = Plantar flexion 
and inversion
 CFL
 MOI: Dorsiflexion
 Syndesmosis
 Squeeze Test
 CTQ: ER Stress Test
 “High” Ankle Sprain Delay 
Return to Play

Miller MD. Review of Sports Medicine and Arthroscopy

Management
 Immobilization
 Screw / tightrope 
fixation if unstable 
mortise
 Longer Return to play

Miller MD. Review of Sports Medicine and Arthroscopy
Ankle Arthroscopy
 Indications
 OC Lesions, synovitis, impingement
 CTQ: Portals
 AL: b/w Lat Mall and peroneus
tertius
▪ Risk: Dorsal intermediate branch 
of SPN 
 AM: b/w TA and med mall
▪ Risk: SV and SN
 PL:  b/w peroneal tendons and 
Achilles
▪ Risk: Sural N and Small Saph Vein 
 AC: b/w EDC and EHL
▪ Risks: DPN and Ant Tib artery Ferkel JD. An Illustrated Guide to Small Joint Arthroscopy

 Tendon Injuries: Dx and Tx of post tib/peroneal/fhl

injuries
 Non‐op Tx of Achilles: higher re‐rupture rate, loss of 
power
 Recognize and treat os trigonum / subfibulare
 Ankle sprain: stress testing for each ligament
 Understand when syndesmosis needs op fixation
 Ankle arthroscopy portals and risks
 Most Common Location of OCD of talus: Medial
 Turf toe pathophysiology and long term sequellae
  Treat conservatively initially
 PE findings for ITB Syndrome
 Don’t forget about stress fractures in runners
 Ober test
 Female athlete triad

 Common stress fracture locations
 Femoral neck
 Anterior tibia
 Tarsal navicular
 Anterior most commonly affected  in Exertional
compartment syndrome
 Most common sites of nerve entrapment of LE
 Popliteal artery entrapment PE
 History most important part of PPE
 EKG/Echo/Labs not indicated for all PPE
 Majority of Sudden Death in young athletes 
due to cardiovascular 
 1) HCM
 2) Commotio Cordis

 Signs and Symptoms of MTBI
 LOC and amnesia not predictive of severity of 
MTBI
 Symptom free, neurocognitive baseline, graded 
exertion prior to RTP
 Longer symptoms and RTP for immature brain
 Second Impact often leads to death
 Repetitive MTBI: CTE
 Leave helmet on, remove facemask for airway 
all c‐spine trauma
 RTP for stingers with full motion and strength
 Sickle Cell Trait is heterozygous and a point 
mutation on B chain of Hg
 Risk factors for Sickle crisis
 Sickle crisis has normal body temperature
 Treatment is supportive
 Death from sickle crisis is from rhabdomyolisis
or arrythmia

 Know safe glucose ranges for athletes with 
DM
 Insulin adjustments for athletes based on 
activity
 Complications of athletes with DM (most 
common: hypoglycemia)
 Evaporative cooling is body’s typical 
mechanism 
 4 phases of Heat Illness
 Heat exhaustion <40 deg, Heat stroke >40 
deg
 Heat stroke tx: ice water immersion
 Recognize symptoms of hypothermia
 Frostbite tx: warm bath 40‐42 deg

 Bacterial infections: 72 hrs abx, no new lesion 48 
hrs, no active lesions to participate
 MRSA: epidemic among athletes, significant 
morbidity, often require IV ABx
 Herpetic lesions crusted and 5 days of Abx to play
 Mono diagnosed by labwork, monospot test, and 
titers
 Symptoms of mono
 RTP with mono (Risk of Splenic Rupture in first 3 
weeks!)
 Test Taking
Strategies
Bashir A. Zikria MD
Assistant Professor
Johns Hopkins School of Medicine - Department of Orthopaedics
Division of Sports Medicine
Anikar Chhabra, MD
Director of Orthopedic Sports Medicine
Banner Good Samaritan Ortho Residency
Arizona State University

Exam Information

• Examination Date
• THURSDAY, July 10, 2014
• Location
• Prometric Testing Centers
Part I Exam

 Written, cognitive exam covering entire field of

orthopaedics
 ~320 multiple-choice questions
 7 hours allowed for exam
 PRACTICE TIMING FOR EXAM

PART I EXAM

• Information from entire 5 years of residency

• ~ 33% - basic knowledge stays consistent
• ~ 67% - clinical knowledge
• 30%-35% of questions have been used previously
• CTQ: Review SAE and OITE questions
• Criterion-referenced exam - implies that all candidates
with requisite knowledge can pass
Part I Boards Pass Rate

• 2011 Statistics
• 832 Test Takers
• 79 % passed 21% Failed
• 2012 Statistics
• 865 Test takers
• 85% passed 15% Failed
• 2013 Statistics
• 832 Test takers
• 84% passed 16% Failed
• General Stats
• ~ 85-90% of first-time test takers
• ~ 79% of repeat examinees
• ~ 50% of repeat test-takers

WHY PEOPLE DO NOT PASS?:

• Poor preparation
• Remember to review subjects.
• Very difficult to learn new subjects or concepts at this time.
• Since should have learned subject from 5 years of residency.
• Takes valuable time from actually reviewing subject.
• Set a schedule of studying.
• Poor test-taking skills
• High anxiety
Standardized Tests

• Over 1,100 applicants for ~555 positions

• Previous standardized testing includes the SAT, MCAT,
USMLE Steps I, II, and III
• Thus it can be inferred that orthopaedic residents
generally performed well on those exams

USLME vs Part I Boards

• Studies are conflicting regarding the USLME Step-I and

Step-II scores as being a predictor of Part I exam
performance
• Evidence suggest that scoring in the lowest third of the
OITE in PGY-3 and PGY-4 stand a greater chance of failing
the ABOS Part I exam
OITE vs Part I Boards

• Differences in psychometrics between the exams may

limit the ability to find a correlation for performance
• OITE questions are submitted based on subspecialties
• Part I questions have been previously administered to board-
certified orthopaedic surgeons, analyzed statistically, and
selected for inclusion on the basis of their psychometrics

Types of Questions: Cognitive Level

• Taxonomy I – Recall
• Anatomy
• Basic science
• Taxonomy II – Interpretation or comprehension
• Written description
• Image
• Taxonomy III – Problem solving
• Knowledge application
Construction of a Question

• Stem
• Question
• Responses
• One preferred response
• Four distractors
• +/-Figures

Test-Taking for Multiple-Choice

Formats
• Research has indicated that adequate preparation in
test-taking skills can improve test performance
• Familiarity with characteristics and content of tests
• Test prepararion
• Test wiseness
• Management of test anxiety
Familiarity with Characteristics
Contents of Tests
• Purpose of test
• QUALIFIED (responsible) orthopaedic surgeons
• Know key points of diagnosis
• LACHMAN TEST – SENSITIVE ACL RUPTURE
• Know indications of surgery
• Very important to treat conservatively if surgery is not
immediately necessary
• Know how to recognize complications
• ASPIRATION – ANY SUSPICION OFJOINT INFECTION
• ACL RECON – LOSS OF MOTION
• ARTHROFIBROSIS
• INCORRECT PLACEMENT OF FEMORAL TUNNEL

Familiarity with Characteristics

Contents of Tests
• Purpose of test
• Areas to be covered
• 33% - basic knowledge – stays consistent throughout the years
• Memorization questions
• 17% - pediatrics
• 25 - 30% - trauma
• 15 - 20% - adult reconstruction
• ~5% - sports medicine
• Seems small part of test BUT IF ANSWER MOST CORRECTLY ADD ABOUT 5%
TO YOUR SCORE!!!!
Test Preparation

• There is debate over whether or not enrolling in a test

preparation course will improve performance (at the very
least it cannot hurt)
• HELPS WITH ORGANIZING AND AT LEAST REVIEWS ALL TOPICS
ONCE
• Time-management skills –answer all questions
• Metacognitive skills – skills that build upon what you know
about own thinking: Ability to learn to learn. learning
goals, learning styles, evaluate own learning.
• Study strategies – quality more important than quantity –
Its not the amount of time studying but the actual time
reviewing the material in depth!

Test Preparation

• Study location – select a specific place and do not use it

for non-study activities
• Preferred learning styles – visual, auditory, tactile
• Study groups – vs independently (study with someone
who is serious about doing well and can contribute; may
not be a friend) – can really help you or hurt
• Memory strategies
Test Preparation

• Use information as quickly as it is learned

• Associate new information with learned information
• Visual imagery (i.e. Italy is shaped like a boot)
• Overlearn – and keep track of repetitions required to do
this
• Mneumonics

Test Wiseness

• Refers to the ability to use characteristics and format of a

test to improve performance
• Standardized, multiple choice exams test recognition of
information, not recall, over a short period of time to
evaluate knowledge, comprehension and application
(requires both speed and accuracy)
Test Wiseness

• Strategies for multiple-choice tests

• Read carefully but answer quickly – ANSWER ALL QUESTIONS
• Look for clue words in the stem – establish diagnosis or treatment
• Complete the easiest questions first
• Eliminate the incorrect options first – MUST BE ABSOLUTELY SURE
• Eliminate responses that are the same
• Eliminate absurd or humorous options
• Eliminate absolute options (always and never)
• Pure guess vs. educated guess

Test Wiseness

• SPLASHDOWN technique – write down info difficult to

recall when exam is received (i.e. brachial plexus)
Test Wiseness

• Underline relevant options in a complex stem

• “All of the above are true” is a good guess if 2 correct
options can be identified
• “None of the above” cannot be correct if 1 correct
option can be identified

Test Wiseness

• Do not read too much into questions or try to find hidden

meanings (even best test-takers can fall into this trap)
• Do not second-guess the motivation of test-developers
(they are not trying to trick you; the average cost to
create a question is $2,000 and they work hard to write a
good and fair question)
• Do not assume anything (i.e. no way there can be 3 “B” in
a row)
• Suspend judgement until all options have been read (all
may be true but only one will be the best or most
important)
Test Wiseness

• The most attractive distractor (incorrect answer) is often

placed first
• Do not change answers unless new information indicates
they should be changed
• Educated guessing (not blind or random) can be a good
strategy
• “SCORER” technique
• S – schedule your time (210 minutes/160 questions=1.3
minutes(78sec)/ question)
• C – use clue words
• O – omit difficult questions with the first pass – AT LEAST PURE
GUESS – HAVE TO ANSWER ALL QUESTIONS
• R – read carefully
• E – estimate answers by writing “E” beside estimated answers
• R – review test and make sure all questions have been answered

Test Wiseness

• When you have no clue…….do not punt

• PURE GUESS
• Select the nonparallel option
• Select the longest option
• Try to narrow it down to two best choices and select the one you
first thought was correct
• If you cannot do that then go with the letter of the day
Management of Test Anxiety

• DTA (Debilitating Test Anxiety)

• Failure to pass professional licensing exams despite sufficient
energy and time spent in preparation
• No evidence of health problems, learning disabilities, clinical
depression, drug/alcohol dependency, etc…
• Except for performance on multiple-choice tests, there is realistic
sense of being competent in professional setting
• Other demanding academic, extracurricular, and clinical
activities are not impaired by anxiety

Management of Test Anxiety

• Behavioral modifications
• Behavioral rehearsal
• CANNOT THINK FAILURE
• Reduce potential distractions caused by anxiety on test day
• Imagine feelings that would be present on test day
• Practice run through all steps
Management of Test Anxiety

• Psychoeducational techniques
• Error analysis - identify areas of relative strength and weakness
• Maximize probability of correct answer
• Cover answers while reading question
• Choose first of two answers if all but two possible choices can be
eliminated
• When no idea which of 3+ answers is correct, use “letter of the day”
strategy (e.g., answer all questions with B)

Management of Test Anxiety

• Relaxation approaches
• Self-control triad
• Thought stopping
• Deep relaxing breaths
• Visualizing a pleasant scene
• Count backwards from 5 to 1
• Maintain a healthy lifestyle – fitness, nuitrition, rest, limited
caffeine
• Prayer and meditation
• Seek professional help
Management of Test Anxiety

• Other interventions
• Regular moderate exercise: lower anxiety, improved mood,
enhanced self-concept, quicker reaction time, better attention,
stronger reasoning skills
• Cognitive techniques: reduce negativism, self-criticism,
helplessness

Management of Test Anxiety

• Mentor - preceptor
• Regular review of outlined study plan
• Individualized coaching
• Problem-based study groups
• Evaluation of study skills
• Weekly reading assignments/test
• Get organized and have a plan of attack
Exam Preparation Checklist

• Components
• Knowledge
• Preparation
• Test-taking skills
• Knowledge: study materials
• Old exams
• OKU (2 most recent)
• AAOS Self-Assessment exams
• Review course(s)
• Review books
• Residency curriculum
• Handouts
• Journal club material
• Personal notes

Exam Preparation Checklist

• Preparation
• Strategic study plan leading up to exam
• Spend final week reviewing basic knowledge, areas of
weakness as determined by OITE
• BASIC SCIENCE – Mostly Memorization
• Structured study habits
• Review Tutorial on ABOS website
The Day Before Checklist

• Review test instructionss and know where to be for the

test:
• Brief review
• Gather materials
• Limit medications
• Eat a light dinner
• Reduce caffeine
• Good night’s sleep

Exam Day

• Eat a breakfast high in complex carbohydrates

• Arrive early but not too early
• The total time allotted for the examination is 9 hours
• 8 hours of testing time
• 40 minutes of break time
• 20 minutes for lunch
• Answer all questions
• Be confident and maintain stamina
Practical Pointers

Use old exams to identify frequently used “signal”

words and practicing correctly

Key Test Questions

The MRI scans show what pathologic condition?

1. Articular-sided supraspinatus tendon tear

2. Bursal-sided supraspinatus tear
3. Superior labral tear
4. Humeral avulsion of the anterior glenoid ligament
5. Avulsion of the anterior inferior glenohumeral ligament
Key Test Questions

What portion of the pitching phase creates forces

approaching the tensile limit of the medial collateral
ligament?

1. Early cocking phase

2. Late cocking phase
3. Early acceleration phase
4. Follow-through phase
5. Deceleration phase

Key Test Questions

If the quality of the tendon is poor at the lateral

attachment of a partial bursal side rotator cuff tear (more
than 3 mm of footprint exposure or greater than 25%
thickness), what should the surgeon do?

1. Use an autogenous fascial graft.

2. Use an allograft augmentation.
3. Complete the tear and then repair the tendon.
4. Perform a trans-tendon repair.
5. Biopsy the tissue.
Key Test Questions

A 24-year-old professional male soccer player has lower

abdominal pain on exertion. He has pain with resisted hip
adduction and with sit-ups. There is no palpable inguinal
hernia with a Valsalva maneuver. Nonsurgical management
has failed to provide relief. After ruling out malignancies, what
is the next most appropriate step in management?

1. Additional nonsurgical management

2. Referral to a general surgeon
3. Ultrasound of the scrotum
4. CT of the pelvis
5. Cortisone injection

Key Test Questions

What structure is the primary restraint to inferior translation of

the shoulder?
1. Middle glenohumeral ligament
2. Subscapularis
3. Long head of the biceps
4. Coracohumeral ligament
5. Coracoacromial ligament

Rotator Interval Structures?

Key Test Questions

A collegiate division I football player ruptures his anterior

cruciate ligament (ACL). After counseling him, you agree to
perform a double-bundle ACL reconstruction. Which of the
following is a correctstatement for this technique?

1. The anteromedial (AM) bundle limits translation and the

posterolateral (PL) bundle controls rotation.
2. The PL bundle limits translation and the AM bundle controls
rotation.
3. The anterolateral (AL) bundle limits translation and the
posteromedial (PM) bundle controls rotation.
4. Both the AL and the PM control rotation equally.
5. The AL bundle controls rotation and the PM bundle limits
translation.

Key Test Questions

Which of the following clinical findings is most often seen with
the MRI scan findings shown in Figures 19a through 19c?

1. Atrophy of the lateral shoulder

2. Atrophy of the posterior shoulder
3. Sensory deficit of the lateral shoulder
4. Sensory deficit of the posterior shoulder
5. Sensory deficit of the anterior shoulder

What nerve and location of cyst?

Key Test Questions

What is the most common complication associated with

surgical repair of an Achilles tendon rupture?

1. Infection
2. Neurologic injury
3. Loss of motion
4. Re-rupture
5. Skin healing problems

Key Test Questions

Internal impingement is characterized by which of

the following anatomic lesions?

1. Subscapularis tear
2. Bursal-sided rotator cuff tear
3. Articular-sided rotator cuff tear
4. Tight anterior capsule
5. Laxity of the posterior capsule
Key Test Questions

A 17-year-old basketball player sustained an

inversion twisting injury to the left ankle with the foot
plantar flexed approximately 20 degrees. Which of
the following ankle ligaments is most likely to be
injured by this mechanism?

1. Anterior tibiofibular
2. Posterior tibiofibular
3. Anterior talofibular
4. Calcaneofibular
5. Posterior talofibular

Key Test Questions

In the anterior cruciate ligament-deficient knee, what

structure provides an important secondary restraint to
anterior tibial translation?

1. Anterior horn of the lateral meniscus

2. Posterior cruciate ligament
3. Posterior horn of the medial meniscus
4. Popliteus tendon
5. Quadriceps muscle

ACUTE ACL vs Chronic ACL

Key Test Questions

An 18-year-old woman injures her left knee playing soccer. At

the time of anterior cruciate ligament(ACL) reconstruction,
she was noted to have an irreparable posterior horn medial
meniscus tear. Partial meniscectomy will have what primary
effect?

1. Increase medial compartment peak loads

2. Increase medial compartment contact area
3. Decrease in situ forces in the ACL graft
4. Decrease anterior tibial translation
5. Increase posterior tibial translation

Key Test Questions

Which of the following best describes the pathologic anatomy

of cam impingement of the hip?

1. Retroversion of the acetabulum

2. Posteroinferior labral tears
3. Morphologic abnormality of the femoral head
4. Femoral anteversion
5. Femoral head osteonecrosis
Key Test Questions

What is the predominant type of collagen in the tissue

resulting from the surgical procedure shown in the figures
below?
1. Type I
2. Type II
3. Type III
4. Type IX
5. Type X

Key Test Questions

A 21-year-old collegiate wrestler and rugby player reports an

8-month history of groin pain. Examination reveals a slight
Trendlenburg gait, abductor weakness, hip flexion of 90
degrees, and internal rotation of 10 degrees. A radiograph
and MRI arthrogram are shown in Figures 43a and 43b. What is
the next most appropriate step in management?

1. Abduction orthosis
2. DEXA scan
3. Bone scan
4. Hip osteotomy
5. Hip arthroscopy and osteoplasty
Key Test Questions

A 57-year-old man who plays recreational sports reports pain in his

dominant shoulder. An MR arthrogram is shown in Figure 57. During
arthroscopy of the shoulder, what pathology is most likely to be
found?

1. Complete disruption of the transverse humeral ligament

2. Acromioclavicular joint arthritis
3. Absent coracohumeral ligament
4. Subscapularis tear and biceps subluxation
5. Complete rupture of the short head of the biceps

Key Test Questions

The sublime tubercle of the elbow serves as the insertion site of

the
1. anterior bundle of the medial collateral ligament.
2. posterior bundle of the medial collateral ligament.
3. transverse bundle of the medial collateral ligament.
4. annular ligament.
5. lateral collateral ligament.
Key Test Questions

An 18-year-old female Marine Corps recruit enters basic

training. Her enlistment history and physical examination
showed that she was an elite high school cross country runner.
What is her most significant risk factor for a femoral or pelvic
stress fracture during basic training?
1. Running mileage during the 2 months prior to basic training
2. Self-rated fitness
3. Running frequency during the 2 months prior to basic
training
4. No menstrual bleeding during the year prior to basic
training
5. Race/ethnicity

Key Test Questions

An 18-year-old high school basketball player is being treated

for Achilles tendinitis. What type of strengthening exercise has
been shown to be helpful in the later phases of rehabilitation?

1. Eccentric
2. Isokinetic
3. Concentric
4. Isometric
5. Isotonic
Key Test Questions

During a knee arthroscopy on a 38-year-old patient with

isolated medial knee pain and no lateral symptoms, a routine
examination of the lateral compartment reveals a discoid
lateral meniscus. The discoid lateral meniscus is not torn. Based
on these findings, what is the most appropriate action?

1. Complete lateral meniscectomy

2. Lateral meniscal repair
3. Saucerization of the lateral meniscus
4. Microfracture of the lateral femoral condyle
5. Do nothing surgically to the lateral meniscus

Key Test Questions

Which of the following types of intra-articular pathology is

associated with lateral meniscal cysts?

1. Discoid meniscus
2. Posterolateral corner injury
3. Vertical meniscal tears
4. Middle third lateral meniscal tears
5. Popliteus tendon tears
Key Test Questions

Histologic studies of surgically resected tissue in lateral

epicondylitis demonstrate which of the following findings?

1. Chondroblastic proliferation
2. Angiofibroblastic tendinosis
3. Significant active inflammation
4. Primarily calcium deposition
5. No normal tendon histology

Key Test Questions

Which of the following is the most cost-effective method of

screening for idiopathic hypertrophic cardiomyopathy?

1. Obtaining a history of chest pain, syncope, or family

history of early cardiac death during the initial physical
examination
2. Screening echocardiogram
3. Screening EKGs
4. Auscultation of the heart
5. Exercise stress test
Key Test Questions

Which of the following can be seen in the heart of a well-

conditioned athlete?

1. Decreased stroke volume

2. Decreased cardiac output
3. Decreased resting heart rate
4. Decreased ventricular wall thickness
5. Decreased vagal tone

Key Test Questions

A college athlete on a scholarship has a medical condition that you feel

presents a life-threatening risk to him with participation in athletics.
Because of the gravity of this decision and the potential effect it can
have on the student/athlete’s future, the college asks for your guidance.
As the team physician for the college, what is your ethical obligation?

1. Ban the athlete from sports participation.

2. Allow the athlete to participate as it is his constitutional right to do so.
3. Advise the college to revoke the athlete’s college scholarship.
4. Offer no opinion as it is a matter strictly between the college and the
athlete.
5. Recuse yourself from all decision making and advise the athlete to get
an opinion from a third-party physician who is not employed by the
college or university.
Key Test Questions

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GOOD LUCK