Knee Arthroscopy — MCQs
In meniscus injury, 'Locking'-that is sudden inability to extend the knee fully is a feature of:
Complications of sling procedures (TVT) for USI are all except:
Which of the following is an intra-articular tendon?
An athlete sustained an injury around the knee joint, suspecting cartilage damage. Which of the following is the investigation of choice?
Which one of the following arteries pierces the oblique popliteal ligament of the knee joint?
While playing football, a 19-year-old college student receives a twisting injury to his knee when being tackled from the lateral side. Which of the following conditions most likely has occurred?
Most common complication of intertrochanteric fracture femur is:
Heller's myotomy is done for
Manoeuvre carried out for diagnosing medial meniscus injury is:
An athlete sustained an injury around the knee joint with suspected cartilage damage. Which of the following is the investigation of choice?
Knee Arthroscopy Indian Medical PG Practice Questions and MCQs
Question 1: In meniscus injury, 'Locking'-that is sudden inability to extend the knee fully is a feature of:
- A. Anterior horn tear
- B. Bucket handle tear (Correct Answer)
- C. Horizontal tears
- D. Posterior horn tear
Explanation: ***Bucket handle tear*** - A **bucket handle tear** is a specific type of **longitudinal tear** where a large segment of the meniscus is displaced into the intercondylar notch, physically blocking knee extension and leading to **locking**. - This tear typically affects the **medial meniscus** and is a classic cause of **mechanical locking** where the knee cannot be fully straightened. *Anterior horn tear* - Tears of the **anterior horn** are less common than posterior horn tears and rarely cause **locking** unless they are extensive and displace significantly. - While they can cause pain and instability, they are not the primary cause of acute, complete mechanical **locking**. *Horizontal tears* - **Horizontal tears** separate the meniscus into superior and inferior halves and are often degenerative. - They typically cause pain and swelling but are less likely to cause a distinct mechanical **locking** sensation compared to displaced bucket handle tears. *Posterior horn tear* - **Posterior horn tears** are the most common type of meniscus injury and can cause pain, swelling, and sometimes catching. - While they can impede movement, they usually do not cause the complete, irreversible **locking** characteristic of a displaced bucket handle fragment.
Question 2: Complications of sling procedures (TVT) for USI are all except:
- A. Obturator nerve injury is about 10% (Correct Answer)
- B. Overactive bladder in about 7% cases
- C. Injury to bladder and wound haematoma
- D. Sling erosion particularly with polytetrafluoroethylene (Goretex)
Explanation: ***Obturator nerve injury is about 10%*** ✓ **CORRECT ANSWER (NOT a complication of TVT)** - **Obturator nerve injury** is exceedingly rare during **TVT (Tension-free Vaginal Tape)** procedures, which use a retropubic approach through the space of Retzius. - This complication is primarily associated with **TOT (Trans-Obturator Tape)** procedures where the tape passes near the obturator foramen, not with standard retropubic TVT. - The incidence of obturator nerve injury in TVT is essentially negligible (<0.1%), nowhere near 10%. *Overactive bladder in about 7% cases* - **De novo overactive bladder (OAB)** symptoms or worsening of pre-existing OAB can occur in 3-15% of patients after TVT procedures, with 7% being a commonly cited figure. - This occurs due to changes in bladder neck support, urethral kinking, or irritation from the sling material. *Injury to bladder and wound haematoma* - **Bladder injury/perforation** occurs in 2-5% of TVT cases due to the retropubic passage of needles close to the bladder, which is why intraoperative cystoscopy is routinely performed. - **Wound hematoma** can occur at the vaginal or suprapubic incision sites as a common surgical complication from tissue dissection and bleeding. *Sling erosion particularly with polytetrafluoroethylene (Goretex)* - **Sling erosion** into the vagina or urethra is a documented complication of synthetic slings, with rates of 0.5-3% for modern materials. - **Polytetrafluoroethylene (Goretex)**, an older first-generation mesh material, was associated with significantly higher rates of erosion (up to 10%) and infection compared to modern monofilament polypropylene meshes, which is why it has been largely discontinued for sling procedures.
Question 3: Which of the following is an intra-articular tendon?
- A. Anconeus
- B. Semitendinosus
- C. Popliteus (Correct Answer)
- D. Sartorius
Explanation: ***Popliteus*** - The **popliteus tendon** originates within the knee capsule (intra-articular) before emerging to insert onto the posterior tibia. - It plays a crucial role in **unlocking the knee joint** from full extension and contributes to posterior stability. *Anconeus* - The **anconeus muscle** is located on the posterior aspect of the elbow, extending from the lateral epicondyle of the humerus to the ulna. - It is an **extra-articular muscle** that assists in elbow extension and stabilization. *Semitendinosus* - The **semitendinosus** is one of the hamstring muscles, located in the posterior thigh. - Its tendon contributes to the **pes anserinus**, inserting on the medial aspect of the tibia distal to the knee joint, making it an extra-articular tendon. *Sartorius* - The **sartorius** is the longest muscle in the body, running obliquely across the anterior aspect of the thigh. - Its tendon also contributes to the **pes anserinus**, inserting medially to the knee joint, and is considered extra-articular.
Question 4: An athlete sustained an injury around the knee joint, suspecting cartilage damage. Which of the following is the investigation of choice?
- A. Clinical examination
- B. Arthroscopy (Correct Answer)
- C. Arthrotomy
- D. X-ray
Explanation: ***Arthroscopy*** - **Arthroscopy** is the definitive investigation for **cartilage damage** as it allows for direct visualization of the knee joint's internal structures. - It not only confirms the diagnosis but can also facilitate simultaneous **repair or débridement** of damaged cartilage. *X-ray* - **X-rays** are primarily used to assess **bone structures** and detect fractures or significant joint space narrowing, not soft tissue injuries like cartilage. - They are generally **insufficient** for diagnosing subtle or early cartilage damage. *Clinical examination* - A **clinical examination** is crucial for initial assessment and suspicion of cartilage injury, but it cannot definitively diagnose the extent or type of cartilage damage. - It helps guide further investigations but is **not specific enough** to confirm cartilage integrity. *Arthrotomy* - **Arthrotomy** involves a larger incision to open the joint, which is more **invasive** than arthroscopy and typically reserved for open surgical repairs or complex reconstructions, not as a primary diagnostic tool for cartilage. - It carries a **higher risk of complications**, such as infection and prolonged recovery, compared to arthroscopy.
Question 5: Which one of the following arteries pierces the oblique popliteal ligament of the knee joint?
- A. Medial superior genicular artery
- B. Lateral superior genicular artery
- C. Middle genicular artery (Correct Answer)
- D. Posterior tibial recurrent artery
Explanation: Detailed anatomical study reveals that the **middle genicular artery**, a branch of the popliteal artery, is unique among the genicular arteries in that it **pierces the oblique popliteal ligament**. It then supplies the **cruciate ligaments**, synovial membrane, and the posterior aspect of the **menisci** within the knee joint. *Medial superior genicular artery* - This artery runs **above the medial condyle of the femur** and contributes to the genicular anastomosis around the knee joint. - It does **not pierce the oblique popliteal ligament**; instead, it passes superficial to it. *Lateral superior genicular artery* - This artery passes **above the lateral condyle of the femur**, contributing to the blood supply of the knee joint. - Like the medial superior genicular artery, it runs **superficial to the oblique popliteal ligament**, rather than piercing it. *Posterior tibial recurrent artery* - The **posterior tibial recurrent artery** is a variable branch, usually originating from the posterior tibial artery, which ascends to the knee. - It typically supplies the posterior aspects of the knee joint but **does not pierce the oblique popliteal ligament**.
Question 6: While playing football, a 19-year-old college student receives a twisting injury to his knee when being tackled from the lateral side. Which of the following conditions most likely has occurred?
- A. Tear of the medial meniscus (Correct Answer)
- B. Ruptured fibular collateral ligament
- C. Tenderness on pressure along the fibular collateral ligament
- D. Injured posterior cruciate ligament
Explanation: **Tear of the medial meniscus** - A **twisting injury** to the knee, especially when tackled from the lateral side (which can force the leg into valgus stress), commonly causes a **tear of the medial meniscus**. - The **medial meniscus** is less mobile and more firmly attached than the lateral meniscus, making it more susceptible to injury during twisting forces. *Ruptured fibular collateral ligament* - A rupture of the **fibular collateral ligament (FCL)**, also known as the **lateral collateral ligament (LCL)**, typically results from a **varus stress** (a blow to the medial side of the knee), which is contrary to a tackle from the lateral side. - While twisting can contribute to knee injuries, isolate FCL tears from a lateral-side tackle are less likely than meniscal damage. *Tenderness on pressure along the fibular collateral ligament* - Tenderness along the **fibular collateral ligament** would indicate an injury to this structure, but a twisting injury from the lateral side is less likely to directly damage the FCL compared to the medial structures. - This symptom alone does not fully explain the mechanism of injury and the common resulting pathology in this scenario. *Injured posterior cruciate ligament* - The **posterior cruciate ligament (PCL)** is most commonly injured by a direct blow to the anterior tibia when the knee is flexed (a **dashboard injury**) or by a hyperflexion injury. - A twisting injury from the lateral side is a less common mechanism for isolated PCL injury.
Question 7: Most common complication of intertrochanteric fracture femur is:
- A. Malunion (Correct Answer)
- B. Nerve injury
- C. Osteoarthritis
- D. Non-union
Explanation: ***Malunion*** - **Malunion** is the most common complication of intertrochanteric fractures, particularly with unstable fracture patterns or inadequate reduction and fixation. - This typically results in leg length discrepancy, gait disturbance, and persistent pain due to abnormal alignment. *Nerve injury* - **Nerve injury** is a rare complication of intertrochanteric fractures, as the major nerves (e.g., sciatic, femoral) are not in close proximity to the fracture site. - While possible with severe trauma or surgical errors, it is not considered the most common complication. *Osteoarthritis* - **Osteoarthritis** can develop years after an intertrochanteric fracture due to altered biomechanics, but it is a long-term sequela, not an immediate or most common post-fracture complication. - Early complications like malunion or infection are more prevalent. *Non-union* - **Non-union** is relatively uncommon in intertrochanteric fractures because this area of the femur has an excellent blood supply, which promotes healing. - This complication is more frequently seen in femoral neck fractures due to their tenuous blood supply.
Question 8: Heller's myotomy is done for
- A. Zenker's diverticulum
- B. Achalasia cardia (Correct Answer)
- C. Hiatus hernia
- D. Diffuse esophageal spasm
Explanation: ***Achalasia cardia*** - **Heller's myotomy** (esophagomyotomy) is the definitive surgical treatment for **achalasia cardia** - The procedure involves cutting the circular muscle fibers of the **lower esophageal sphincter (LES)** to relieve the functional obstruction - It addresses the primary pathology of achalasia: **failure of LES relaxation** and absence of esophageal peristalsis - Often combined with a partial fundoplication (Dor or Toupet) to prevent postoperative reflux *Zenker's diverticulum* - This is a **pharyngeal pouch** that develops at the pharyngoesophageal junction (Killian's triangle) - Treated with **diverticulectomy or diverticulopexy** with cricopharyngeal myotomy - Involves the upper esophageal sphincter, not the LES targeted by Heller's myotomy *Diffuse esophageal spasm* - A primary esophageal motility disorder characterized by **simultaneous, non-peristaltic contractions** - While esophageal myotomy may occasionally be considered in refractory cases, it is not the standard procedure - Management is primarily **medical** (calcium channel blockers, nitrates) rather than surgical *Hiatus hernia* - Involves herniation of the stomach through the esophageal hiatus of the diaphragm - Treated with **fundoplication** (Nissen or partial fundoplication) to reinforce the LES and repair the hiatus - Does not involve cutting the LES muscle as in Heller's myotomy
Question 9: Manoeuvre carried out for diagnosing medial meniscus injury is:
- A. McMurray's test (Correct Answer)
- B. Valgus stress test
- C. Lachmann's test
- D. Varus stress test
Explanation: ***McMurray's test*** - This test is specifically designed to assess for meniscal tears, particularly the **medial meniscus**. - A positive test involves eliciting a **click or pain** when extending the knee from a fully flexed position while internally and externally rotating the tibia. *Valgus stress test* - This test evaluates the integrity of the **medial collateral ligament (MCL)**. - It involves applying a valgus (outward) force to the knee while stabilizing the thigh, looking for increased gapping or pain. *Lachmann's test* - This is the most sensitive test for assessing the integrity of the **anterior cruciate ligament (ACL)**. - It involves gently pulling the tibia anteriorly with the knee flexed at 20-30 degrees, looking for excessive anterior translation. *Varus stress test* - This test assesses the integrity of the **lateral collateral ligament (LCL)**. - It involves applying a varus (inward) force to the knee while stabilizing the thigh, looking for increased gapping or pain.
Question 10: An athlete sustained an injury around the knee joint with suspected cartilage damage. Which of the following is the investigation of choice?
- A. X-ray
- B. Clinical examination
- C. Arthroscopy (Correct Answer)
- D. Arthrotomy
Explanation: **Explanation:** The investigation of choice for suspected intra-articular cartilage damage is **Arthroscopy**. It is considered the **"Gold Standard"** because it allows for direct visualization of the articular surfaces, menisci, and ligaments under magnification. Unlike imaging, it provides a dynamic assessment of the tissue's integrity and allows the surgeon to perform immediate therapeutic interventions (e.g., debridement or chondroplasty). **Analysis of Options:** * **X-ray (Option A):** X-rays are excellent for visualizing bony injuries or fractures but are poor at showing soft tissues like cartilage or menisci. They are usually the first-line screening tool but are not definitive for cartilage damage. * **Clinical Examination (Option B):** While essential for initial diagnosis (e.g., McMurray’s or Lachman tests), clinical exams are subjective and can be limited by pain, swelling, or muscle guarding in an acute athlete injury. * **Arthrotomy (Option D):** This involves a large surgical incision to open the joint. It is highly invasive and has been largely replaced by arthroscopy due to higher morbidity and longer recovery times. **Clinical Pearls for NEET-PG:** * **MRI vs. Arthroscopy:** While MRI is the investigation of choice for *non-invasive* screening of soft tissue injuries, **Arthroscopy** remains the overall "Gold Standard" for definitive diagnosis and treatment. * **Triad of O'Donoghue:** Often seen in athletes, involving injury to the ACL, MCL, and Medial Meniscus. * **Arthroscopy Media:** Normal saline or Ringer’s Lactate is used to distend the joint during the procedure. * **Common Portals:** The anterolateral portal is the most common primary portal used in knee arthroscopy.
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