This practice set contains high-yield board review questions covering key concepts in Shoulder & Hip Sports. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.
Question 201
Topic: Shoulder & Hip Sports
A 45-year-old male presents to the ED after an electrical shock. His arm is locked in internal rotation and adduction. Radiographs show a 'lightbulb' sign. What associated bony defect is most commonly seen?
Correct Answer & Explanation
. Reverse Hill-Sachs lesion
Explanation
Electrical shocks and seizures commonly cause posterior shoulder dislocations. These are frequently associated with a reverse Hill-Sachs lesion, which is an impaction fracture of the anteromedial humeral head.
Question 202
Topic: Shoulder & Hip Sports
A 16-year-old female gymnast complains of bilateral shoulder pain and a sensation of her shoulder 'slipping' during activities. She has generalized ligamentous laxity. Sulcus sign is positive. What is the most appropriate initial management?
Correct Answer & Explanation
. Physical therapy focusing on periscapular and rotator cuff strengthening
Explanation
The initial management for multidirectional instability (MDI) is a prolonged course of physical therapy. It should focus heavily on strengthening the rotator cuff and periscapular stabilizers.
Question 203
Topic: Shoulder & Hip Sports
Which of the following best describes an Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) lesion?
Correct Answer & Explanation
. Avulsion of anterior labrum with intact periosteum allowing it to medialize and heal
Explanation
An ALPSA lesion involves an anterior labral tear where the anterior scapular periosteum remains intact. This allows the labrum to medialize and heal in an abnormal position on the glenoid neck.
Question 204
Topic: Shoulder & Hip Sports
A 19-year-old male sustains a first-time traumatic anterior shoulder dislocation during a football game. He is neurologically intact and the shoulder is closed reduced. What is his approximate risk of recurrent instability if managed non-operatively?
Correct Answer & Explanation
. 80-90%
Explanation
The most significant risk factor for recurrent anterior shoulder instability is age at the time of the first dislocation. Patients under 20 years old have a recurrence rate of 80% to 90% with non-operative management.
Question 205
Topic: Shoulder & Hip Sports
A 24-year-old male undergoes arthroscopic stabilization for recurrent anterior shoulder instability. Intraoperatively, he is found to have a 20% glenoid bone loss and an engaging Hill-Sachs lesion. Which of the following procedures involves tenodesis of the infraspinatus into the humeral defect?
Correct Answer & Explanation
. Remplissage procedure
Explanation
The Remplissage procedure involves capsulotenodesis of the infraspinatus tendon into a posterior humeral head defect (Hill-Sachs lesion) to prevent it from engaging the anterior glenoid rim. It is indicated for off-track or engaging Hill-Sachs lesions without critical glenoid bone loss.
Question 206
Topic: Shoulder & Hip Sports
A 16-year-old female gymnast presents with bilateral shoulder pain and a feeling of looseness. She has a positive sulcus sign bilaterally and apprehension with load and shift testing in multiple directions. What is the most appropriate initial management?
Correct Answer & Explanation
. Physical therapy focusing on periscapular and rotator cuff strengthening
Explanation
Multidirectional instability (MDI) is typically atraumatic and characterized by generalized ligamentous laxity. The cornerstone of initial treatment is a prolonged course of physical therapy (minimum 3-6 months) emphasizing dynamic stabilization through rotator cuff and periscapular muscle strengthening.
Question 207
Topic: Shoulder & Hip Sports
During a Latarjet procedure for anterior shoulder instability with significant glenoid bone loss, the coracoid process is osteotomized and transferred to the anterior glenoid. Which nerve is most at risk during the coracoid osteotomy and mobilization of the conjoint tendon?
Correct Answer & Explanation
. Musculocutaneous nerve
Explanation
The musculocutaneous nerve enters the conjoint tendon (coracobrachialis and short head of biceps) approximately 3-8 cm distal to the coracoid tip. It is the nerve most at risk of injury due to traction or errant retractor placement during the Latarjet procedure.
Question 208
Topic: Shoulder & Hip Sports
A 45-year-old male is brought to the emergency department after suffering a generalized seizure. He holds his arm adducted and internally rotated. Radiographs reveal a posterior shoulder dislocation. Which of the following osseous lesions is most commonly associated with this injury?
Correct Answer & Explanation
. Reverse Hill-Sachs lesion
Explanation
Posterior shoulder dislocations, often resulting from seizures or electrocution, force the humeral head against the posterior glenoid rim. This commonly creates an impaction fracture on the anteromedial aspect of the humeral head, known as a reverse Hill-Sachs lesion.
Question 209
Topic: Shoulder & Hip Sports
A 28-year-old male with recurrent anterior shoulder dislocations is undergoing preoperative evaluation. A 3D CT scan is obtained. At what percentage of anterior glenoid bone loss is an arthroscopic soft tissue Bankart repair generally considered to have an unacceptably high failure rate, thus indicating a bony augmentation procedure?
Correct Answer & Explanation
. 20-25%
Explanation
Critical glenoid bone loss is traditionally defined as >20-25% of the inferior glenoid width. In the presence of such bone loss, isolated soft-tissue repair has a high recurrence rate, and a bony augmentation procedure (e.g., Latarjet) is indicated.
Question 210
Topic: Shoulder & Hip Sports
A 68-year-old osteopenic female sustains a fall onto her shoulder, resulting in a displaced greater tuberosity fracture with significant superior retraction. During surgical planning, the surgeon considers the primary muscle responsible for this displacement. Which rotator cuff tendon primarily inserts on the superior facet of the greater tuberosity and is the main driver of superior displacement?
Correct Answer & Explanation
. Supraspinatus
Explanation
Correct Answer: DThe case details the surgical anatomy of the greater tuberosity, stating that the supraspinatus inserts on the superior facet. Its primary action is abduction of the humerus, and its unopposed pull is the main driver of superior displacement in greater tuberosity fractures. The infraspinatus inserts on the middle facet and the teres minor on the inferior facet, both contributing to external rotation. The subscapularis inserts on the lesser tuberosity, and the deltoid is not a rotator cuff muscle, inserting more distally on the humerus.
Question 211
Topic: Shoulder & Hip Sports
A 40-year-old male sustains a fall and presents with a suspected displaced greater tuberosity fracture. Initial radiographs (AP, scapular Y, axillary views) show a possible fracture, but the exact degree of displacement and comminution is unclear. Which of the following imaging modalities is considered essential for detailed pre-operative planning of a displaced greater tuberosity fracture?
Correct Answer & Explanation
. Computed Tomography (CT) scan with 3D reconstructions
Explanation
Correct Answer: CThe case explicitly states that a Computed Tomography (CT) scan with 3D reconstructions is 'essential' for displaced greater tuberosity fractures. It provides detailed information regarding fragment size, shape, number, precise degree and direction of displacement, articular involvement, and comminution, which is critical for surgical planning. While MRI is indicated if there is suspicion of concomitant rotator cuff pathology or labral tears, it is not considered the primary essential imaging for characterizing the bony fracture itself. Ultrasound, arthrography, and dynamic fluoroscopy have more limited roles in initial detailed fracture assessment.
Question 212
Topic: Shoulder & Hip Sports
A 55-year-old female dislocates her shoulder anteriorly after a fall. Post-reduction radiographs demonstrate an associated, minimally displaced greater tuberosity fracture. What is the relationship between this fracture and the risk of a concomitant rotator cuff tear?
Correct Answer & Explanation
. The fracture decreases the likelihood of a concomitant full-thickness rotator cuff tear.
Explanation
In the setting of anterior shoulder dislocation, an associated greater tuberosity fracture is inversely related to the presence of a rotator cuff tear. The failure occurs through the bone (avulsion) rather than the tendinous insertion of the rotator cuff.
Question 213
Topic: Shoulder & Hip Sports
During open reduction and internal fixation of a proximal humerus fracture extending into the greater tuberosity, you use heavy non-absorbable sutures to secure the tuberosity fragment. Which muscle's tendon insertion are you primarily capturing to counteract the superior deforming force on the greater tuberosity?
Correct Answer & Explanation
. Supraspinatus
Explanation
The supraspinatus tendon attaches to the superior facet of the greater tuberosity and provides a strong superior and medial deforming force. The infraspinatus and teres minor pull the fragment posteriorly.
Question 214
Topic: Shoulder & Hip Sports
A 45-year-old skier sustains an anterior shoulder dislocation with an associated isolated greater tuberosity fracture.
The dislocation is successfully reduced in the emergency department. Post-reduction radiographs demonstrate the greater tuberosity fragment remains displaced 7 mm superiorly. What is the most appropriate definitive management?
Correct Answer & Explanation
. Open reduction and internal fixation of the greater tuberosity
Explanation
Superior displacement of a greater tuberosity fracture greater than 5 mm is a widely accepted indication for surgical fixation. Failure to reduce the fragment can lead to severe subacromial impingement and altered rotator cuff biomechanics.
Question 215
Topic: Shoulder & Hip Sports
During the clinical examination, the patient's left hip demonstrated significantly restricted and painful range of motion (ROM). Key findings included flexion to 80° (normal >120°), extension to 0° (normal 15-20°) with a fixed flexion deformity of 10°, and internal rotation of 5° (normal 30-40°) with severe pain. This specific pattern of ROM restriction, particularly the loss of internal rotation and fixed flexion deformity, is most characteristic of which of the following hip pathologies?
Correct Answer & Explanation
. Advanced primary osteoarthritis of the hip.
Explanation
The described pattern of range of motion (ROM) restriction, particularly the significant loss of internal rotation and the presence of a fixed flexion deformity, is a classic presentation of advanced primary osteoarthritis of the hip. Osteoarthritis typically affects the anterior and superior aspects of the joint first, leading to a progressive loss of internal rotation and extension.
Question 216
Topic: Shoulder & Hip Sports
Anteroposterior (AP) pelvis radiographs of the patient's left hip revealed severe tricompartmental joint space narrowing, subchondral sclerosis, extensive osteophyte formation along the femoral head-neck junction and acetabular rim, and subchondral cyst formation in both the femoral head and acetabulum. There was also evidence of mild acetabular retroversion indicated by a positive cross-over sign, and superolateral migration of the femoral head. According to the Kellgren-Lawrence classification, these findings are consistent with which grade of osteoarthritis?
Correct Answer & Explanation
. Grade IV (Severe OA)
Explanation
The Kellgren-Lawrence classification system is a widely used radiographic grading scale for osteoarthritis. The described findings of severe tricompartmental joint space narrowing, subchondral sclerosis, extensive osteophyte formation, subchondral cyst formation, and definite deformity of bone ends are the hallmarks of Grade IV osteoarthritis. Grade I involves doubtful narrowing and possible osteophytes. Grade II shows definite osteophytes and possible narrowing. Grade III includes moderate osteophytes, definite joint space narrowing, and some sclerosis. Grade V is not a standard Kellgren-Lawrence grade; the highest is Grade IV, which represents severe disease.
Question 217
Topic: Shoulder & Hip Sports
During a hemiarthroplasty for a comminuted proximal humerus fracture, proper restoration of humeral head height is crucial. Placing the prosthesis too high (proud) relative to the greater tuberosity most commonly results in which of the following complications?
Correct Answer & Explanation
. Subacromial impingement and rotator cuff dysfunction
Explanation
If a humeral prosthesis is placed too proud, it leads to over-tensioning of the rotator cuff and severe subacromial impingement. The correct height is typically achieved by aligning the top of the prosthetic head 5-8 mm above the superior tip of the greater tuberosity.
Question 218
Topic: Shoulder & Hip Sports
During a deltopectoral approach for open reduction and internal fixation of a 3-part proximal humerus fracture, the surgeon has successfully developed the deltopectoral interval and retracted the conjoined tendon medially. As the surgeon prepares to manage the subscapularis and anterior capsule, a blunt Hohmann retractor is placed under the inferior border of the subscapularis. What is the primary purpose of this specific maneuver?
Correct Answer & Explanation
. C. To protect the axillary nerve and anterior humeral circumflex artery from iatrogenic damage.
Explanation
Correct Answer: CThe case study states, 'A blunt Hohmann retractor can be placed under the inferior border of the subscapularis to protect the axillary nerve during subsequent dissection.' It further elaborates that the 'Axillary Nerve courses inferiorly and then posteriorly around the surgical neck of the humerus, approximately 5-7 cm distal to the acromion... Its close proximity to the inferior capsule and surgical neck of the humerus makes it vulnerable during capsular releases, humeral head resection, and fracture fixation. It is often accompanied by the posterior humeral circumflex artery.' The anterior humeral circumflex artery also runs in this vicinity. Therefore, placing a retractor under the inferior border of the subscapularis is a critical step to shield these vital neurovascular structures. Option A is incorrect; while it might provide some counter-traction, its primary role is protection. Option B is incorrect; the musculocutaneous nerve is associated with the conjoined tendon, not typically at risk under the inferior subscapularis. Option D is incorrect; while retractors are used for reduction, this specific placement is for protection. Option E is incorrect; the subscapular artery is deeper and not the primary concern with this specific maneuver.
Question 219
Topic: Shoulder & Hip Sports
A 35-year-old male presents with a large, retracted subscapularis tear following a work-related injury. Surgical repair via the deltopectoral approach is planned. The surgeon opts for a subscapularis tenotomy. Which of the following statements accurately describes the biomechanical implication of this approach and the subsequent repair?
Correct Answer & Explanation
. C. The deltopectoral approach respects the deltoid's innervation, minimizing post-operative weakness and facilitating early rehabilitation.
Explanation
Correct Answer: CThe case study emphasizes the biomechanical advantage of the deltopectoral approach: 'The biomechanical advantage of the deltopectoral approach lies in its respect for the integrity of the deltoid muscle. By dissecting along an internervous plane, the muscle fibers are not transected, preserving the deltoid's origin, insertion, and innervation. This minimizes post-operative weakness and facilitates early rehabilitation.' Option A is incorrect as the approach is internervous, preserving the deltoid. Option B is incorrect; the subscapularis is a primary internal rotator and anterior stabilizer, not an external rotator or posterior stabilizer. Its repair is critical for internal rotation strength and anterior stability. Option D is incorrect; the subscapularis peel is often used in instability surgery (e.g., Bankart repair) to preserve tendon length and allow for better capsular closure, whereas tenotomy is more common for arthroplasty. Option E is partially correct in that the nerves are important, but they enter the deep surface of the muscle, making muscle splitting less risky than extensive subscapularis mobilization without careful nerve identification, and they are not typically 'identified and protected by retracting the subscapularis medially' in the same way the axillary nerve is protected inferiorly.
Question 220
Topic: Shoulder & Hip Sports
A 55-year-old male with severe glenohumeral osteoarthritis is undergoing a total shoulder arthroplasty. After developing the deltopectoral interval and retracting the conjoined tendon medially, the surgeon performs a subscapularis tenotomy. Which of the following statements regarding the subsequent capsulotomy is most accurate?
Correct Answer & Explanation
. C. The inferior limb of a T-capsulotomy must be performed with extreme care to avoid injury to the axillary nerve.
Explanation
Correct Answer: CThe case study describes capsular management: 'Once the subscapularis is mobilized, the underlying anterior capsule is exposed. A T-Capsulotomy is a common approach... The inferior limb must be carefully performed to avoid injuring the axillary nerve.' This highlights the critical vulnerability of the axillary nerve, which courses inferior to the subscapularis and anterior capsule. Option A is incorrect; while a straight vertical capsulotomy is an option, a T-capsulotomy is common and offers excellent exposure, and the key is careful execution, not just the type of incision. Option B is incorrect; an inverted T-capsulotomy is less common, and a standard T-capsulotomy provides excellent exposure. Option D is incorrect; while posterior capsular releases can be performed, the primary capsulotomy in a deltopectoral approach is anterior, and the statement about external rotation is not the direct focus of this question. Option E is incorrect; the capsule is meticulously repaired to restore glenohumeral stability and prevent postoperative subluxation, not left open.
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