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Shoulder & Hip Sports MCQs

Practice Set 111 of 142

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 2201

Topic: Shoulder & Hip Sports

A patient undergoes antegrade intramedullary nailing for a mid-diaphyseal humeral fracture. Which of the following complications is most frequently associated with the entry point through the rotator cuff?

. A. Iatrogenic rotator cuff tear leading to avascular necrosis of the humeral head.
. B. Persistent shoulder pain and impingement symptoms.
. C. Radial nerve palsy.
. D. Nonunion.
. E. Infection of the shoulder joint.

Correct Answer & Explanation

. B. Persistent shoulder pain and impingement symptoms.

Explanation

The entry point for antegrade humeral nailing often passes through or close to the rotator cuff (typically supraspinatus). This can lead to persistent shoulder pain and impingement symptoms (B) due to soft tissue irritation or hardware prominence. While iatrogenic cuff tears can occur, AVN (A) is not a direct consequence of a cuff tear. Radial nerve palsy (C) is more associated with fracture manipulation or plating. Nonunion (D) and infection (E) are general complications, not specific to the rotator cuff entry.

Question 2202

Topic: Shoulder & Hip Sports
A 25-year-old rugby player presents with recurrent anterior shoulder instability. MRI reveals a Bankart lesion, significant glenoid bone loss (>25% of the inferior glenoid width), and a large Hill-Sachs lesion. He continues to experience instability despite rehabilitation and has a high-demand throwing requirement. What is the most appropriate surgical intervention?
. Arthroscopic Bankart repair with remplissage.
. Open anterior capsular shift.
. Latarjet procedure.
. Arthroscopic repair with glenoid bone block augmentation from the iliac crest.
. Rotator interval closure.

Correct Answer & Explanation

. Latarjet procedure.

Explanation

This patient has recurrent anterior shoulder instability in a high-demand athlete with significant glenoid bone loss (>25%) and a large Hill-Sachs lesion (bipolar bone loss). Arthroscopic Bankart repair with remplissage is suitable for a Bankart lesion with a large Hill-Sachs but without significant glenoid bone loss; with >25% glenoid bone loss, it has a very high failure rate. Open anterior capsular shift addresses capsular laxity but not bone deficiencies. Arthroscopic repair with glenoid bone block augmentation from the iliac crest is viable, but the Latarjet procedure is often preferred for high-demand overhead athletes with significant bone loss due to its dynamic stabilization effect. Rotator interval closure is insufficient for such a complex injury. The Latarjet procedure is the most appropriate surgical intervention in this scenario. It addresses the glenoid bone loss by transferring the coracoid process with its attached conjoined tendon to the anterior-inferior glenoid. This procedure increases the glenoid arc, provides a bony block to anterior translation, and the conjoined tendon acts as a 'sling' (dynamic stabilization) that tightens with abduction and external rotation, preventing anterior dislocation. It is particularly effective in high-demand athletes with significant bone loss and has lower recurrence rates compared to isolated soft tissue repairs.

Question 2203

Topic: Shoulder & Hip Sports

A 35-year-old active female presents with chronic groin pain, positive FADIR and FABER tests, and radiographic evidence of a pincer-type femoroacetabular impingement (FAI) with focal labral ossification and early chondral delamination along the acetabular rim. She has failed non-operative management. What is the most appropriate surgical approach for durable symptomatic relief?

. Arthroscopic labral debridement and acetabular rim trimming.
. Open surgical dislocation of the hip, labral repair, acetabular rim osteoplasty, and femoral osteoplasty.
. Arthroscopic labral repair, acetabular rim trimming, and femoral osteoplasty.
. Periacetabular osteotomy (PAO).
. Hip arthrodesis.

Correct Answer & Explanation

. Arthroscopic labral repair, acetabular rim trimming, and femoral osteoplasty.

Explanation

The patient has pincer-type FAI with labral ossification and early chondral delamination, failing conservative treatment. This requires surgical intervention. Arthroscopic labral debridement and acetabular rim trimming (A) might relieve symptoms, but labral repair is generally preferred over debridement, especially with focal ossification indicating chronic pathology. Open surgical dislocation (B) is a robust approach but more invasive with higher morbidity, usually reserved for complex deformities or failed arthroscopic cases. Periacetabular osteotomy (D) is for acetabular dysplasia, not FAI. Hip arthrodesis (E) is a salvage procedure for severe arthritis. For pincer FAI with labral pathology, the goal is to resect the over-covered acetabular rim (rim trimming), and repair or reconstruct the labrum. While the question explicitly states 'pincer-type FAI', many patients have mixed FAI components, thus addressing femoral-sided impingement with femoral osteoplasty is often prudent for a comprehensive treatment.Arthroscopic labral repair, acetabular rim trimming, and femoral osteoplasty (C)is the most appropriate and common contemporary surgical approach. It offers the advantages of minimally invasive surgery while allowing for comprehensive treatment of the pathology: addressing the pincer lesion (rim trimming), dealing with the labral injury (repair is preferred for durability), and correcting any subtle cam component on the femoral side if also contributing to impingement, leading to durable symptomatic relief.

Question 2204

Topic: Shoulder & Hip Sports
A 55-year-old active male presents with chronic glenohumeral instability despite prior arthroscopic capsulolabral repair. Imaging reveals a significant anterior glenoid bone loss (>25%) and a large engaging Hill-Sachs lesion. Which surgical procedure is most indicated for definitive stabilization?
. Revision arthroscopic capsulolabral repair.
. Bankart repair with remplissage.
. Latarjet procedure.
. Superior capsular reconstruction.
. Arthroscopic glenoid augmentation with allograft.

Correct Answer & Explanation

. Latarjet procedure.

Explanation

For recurrent glenohumeral instability with significant anterior glenoid bone loss (>20-25%) and an engaging Hill-Sachs lesion, a Latarjet procedure (coracoid transfer) is generally considered the most reliable option. It addresses both glenoid bone loss and the engaging Hill-Sachs lesion through the 'sling effect' of the conjoined tendon and dynamic stabilization. Revision arthroscopic repair or Bankart repair with remplissage may be insufficient in the presence of substantial bone loss. Superior capsular reconstruction is typically for irreparable rotator cuff tears. Arthroscopic glenoid augmentation with allograft is an option but often considered in less severe bone loss or specific scenarios, and Latarjet is the gold standard for combined bone loss and engaging Hill-Sachs in an active patient.

Question 2205

Topic: Shoulder & Hip Sports

A 68-year-old male presents with chronic, severe right shoulder pain and weakness, with an inability to actively abduct or forward elevate his arm beyond 45 degrees (pseudoparalysis). MRI reveals a massive, irreparable rotator cuff tear involving the supraspinatus, infraspinatus, and subscapularis, with severe fatty infiltration and superior humeral head migration. What is the most appropriate surgical option to restore function and alleviate pain?

. Debridement of the torn cuff and subacromial decompression.
. Latissimus dorsi tendon transfer.
. Superior capsular reconstruction (SCR).
. Reverse total shoulder arthroplasty (rTSA).
. Partial rotator cuff repair.

Correct Answer & Explanation

. Reverse total shoulder arthroplasty (rTSA).

Explanation

This patient has a massive, irreparable rotator cuff tear with pseudoparalysis and superior humeral head migration (cuff tear arthropathy). Debridement and decompression or partial repair are insufficient for such a condition. Latissimus dorsi transfer is an option, primarily to restore external rotation and some abduction, but its efficacy in restoring significant active elevation in pseudoparalysis due to massive tears is limited, especially with subscapularis involvement. Superior capsular reconstruction (SCR) is a newer technique for irreparable tears to restore stability and function but has specific indications and may not be sufficient for severe pseudoparalysis and arthropathy. Reverse total shoulder arthroplasty (rTSA) is the gold standard for treating irreparable rotator cuff tears with pseudoparalysis and/or rotator cuff arthropathy. It reverses the ball-and-socket anatomy, medializing the center of rotation and using the deltoid muscle as the primary elevator, effectively restoring active elevation and significantly improving pain.

Question 2206

Topic: Shoulder & Hip Sports

A 35-year-old professional tennis player reports insidious onset of deep, aching pain in the posterior aspect of her right shoulder, exacerbated by overhead serves. She also notes progressive weakness in external rotation and abduction. Clinical examination reveals isolated atrophy of the infraspinatus and supraspinatus muscles. Electrodiagnostic studies confirm suprascapular neuropathy at the spinoglenoid notch. What is the most common etiology for suprascapular nerve compression at this specific location?

. Traumatic brachial plexus injury.
. Massive rotator cuff tear.
. Ganglion cyst originating from the glenohumeral joint.
. Os acromiale impinging on the nerve.
. Entrapment by the superior transverse scapular ligament.

Correct Answer & Explanation

. Ganglion cyst originating from the glenohumeral joint.

Explanation

Suprascapular neuropathy at the spinoglenoid notch (which affects the infraspinatus motor branch and sensory branches, often sparing the supraspinatus initially if the compression is distal to its innervation) is most commonly caused by a ganglion cyst originating from the glenohumeral joint, particularly associated with posterior labral tears. Repetitive overhead activities can contribute to labral pathology and cyst formation. Compression at the suprascapular notch (by the superior transverse scapular ligament) typically affects both supraspinatus and infraspinatus. While massive rotator cuff tears can sometimes be associated, they are not the primary cause of isolated nerve compression at the spinoglenoid notch. Brachial plexus injury would have a broader deficit. Os acromiale is associated with impingement, not direct nerve entrapment at this location.

Question 2207

Topic: Shoulder & Hip Sports

A 35-year-old professional football player presents with chronic, activity-related groin pain and stiffness, particularly with hip flexion and internal rotation. MRI reveals cam-type femoroacetabular impingement (FAI) and a labral tear at the anterior-superior acetabulum. Despite physiotherapy, symptoms persist, and he wishes to return to play. What is the primary goal of hip arthroscopy in this patient?

. Removal of loose bodies in the hip joint.
. Debridement of osteoarthritic cartilage lesions.
. Reshaping of the femoral head-neck junction and acetabular rim, and repair/debridement of the labral tear.
. Total hip arthroplasty for end-stage arthritis.
. Synovectomy for inflammatory arthritis.

Correct Answer & Explanation

. Reshaping of the femoral head-neck junction and acetabular rim, and repair/debridement of the labral tear.

Explanation

The patient's symptoms and MRI findings are classic for femoroacetabular impingement (FAI) with an associated labral tear. The primary goal of hip arthroscopy for FAI is to correct the underlying bony abnormalities that cause impingement (reshaping the cam lesion on the femoral head-neck junction and/or resecting excessive acetabular rim bone for pincer-type impingement) and to address the associated labral pathology (repairing or debriding the torn labrum). This aims to restore normal hip mechanics, alleviate impingement, reduce pain, and prevent further cartilage damage, ultimately improving function and allowing return to sport. Loose body removal or debridement of generalized OA are not the primary goals for FAI. THA is for end-stage arthritis. Synovectomy is for inflammatory conditions.

Question 2208

Topic: Shoulder & Hip Sports
A 28-year-old professional baseball pitcher complains of deep shoulder pain and a 'dead arm' sensation. An MR arthrogram reveals a superior labral tear that extends into the root of the long head of the biceps tendon, with significant displacement of the biceps anchor into the glenohumeral joint. According to the Snyder classification, what is the best description and optimal surgical treatment of this injury in an active patient?
. Type II SLAP tear; treat with simple labral debridement
. Type II SLAP tear; treat with superior labral repair using suture anchors
. Type III SLAP tear; treat with resection of the bucket-handle tear
. Type IV SLAP tear; treat with biceps tenodesis and labral debridement/repair
. Type V SLAP tear; treat with a standard Bankart repair

Correct Answer & Explanation

. Type IV SLAP tear; treat with biceps tenodesis and labral debridement/repair

Explanation

A Type IV SLAP tear is defined as a bucket-handle tear of the superior labrum that propagates into the long head of the biceps tendon (LHBT). In an active patient with significant involvement of the LHBT (typically >30%), biceps tenodesis combined with labral debridement or repair is the recommended treatment. Type II is simply detachment of the superior labrum/biceps anchor. Type III is a bucket-handle tear with an intact biceps anchor.

Question 2209

Topic: Shoulder & Hip Sports

Which rotator cuff tendon is most commonly involved in degenerative tears?

. Subscapularis
. Supraspinatus
. Infraspinatus
. Teres minor
. Long head of biceps

Correct Answer & Explanation

. Supraspinatus

Explanation

The supraspinatus tendon is by far the most commonly torn rotator cuff tendon. This is attributed to its anatomical position (most susceptible to impingement under the acromion), its critical role in abduction, and its relative hypovascularity in the 'critical zone'.

Question 2210

Topic: Shoulder & Hip Sports

A 55-year-old active male presents with chronic insidious onset of right shoulder pain and weakness, especially with overhead activities. He reports occasional clicking and instability, particularly with abduction and external rotation. Physical exam reveals apprehension in the anterior apprehension test, a positive sulcus sign, and hyperlaxity to generalized ligamentous laxity testing (Beighton score 6/9). MRI shows signs of chronic anterior labral damage but no significant bone loss or large rotator cuff tear. What is the MOST appropriate diagnosis and management strategy?

. Rotator cuff tendinopathy; corticosteroid injection and physical therapy.
. Primary impingement syndrome; subacromial decompression.
. Multidirectional instability (MDI); non-operative management with extensive rotator cuff and scapular stabilization exercises.
. Anterior glenohumeral instability with significant bone loss; Latarjet procedure.
. Superior labrum anterior posterior (SLAP) tear; arthroscopic repair.

Correct Answer & Explanation

. Multidirectional instability (MDI); non-operative management with extensive rotator cuff and scapular stabilization exercises.

Explanation

This patient's presentation of chronic shoulder pain, weakness, clicking, instability, apprehension test positivity, sulcus sign, and generalized ligamentous laxity (Beighton score 6/9) is highly suggestive of Multidirectional Instability (MDI). The chronic labral damage is likely a secondary finding due to chronic instability, not the primary problem.Option A (Rotator cuff tendinopathy) typically presents with pain and weakness but less often with overt instability or apprehension, and the sulcus sign/hyperlaxity point away from primary tendinopathy.Option B (Primary impingement syndrome) is characterized by pain with overhead activities due to rotator cuff compression but usually without the specific instability signs (apprehension, sulcus) or generalized laxity.Option C (Multidirectional instability (MDI); non-operative management with extensive rotator cuff and scapular stabilization exercises) is the MOST appropriate diagnosis and initial management. MDI is often non-traumatic or microtraumatic in origin and is characterized by instability in more than one direction. Given the generalized laxity, strengthening the dynamic stabilizers (rotator cuff, scapular stabilizers) is the cornerstone of treatment. Surgery (e.g., capsular shift) is reserved for those who fail extensive, supervised non-operative management for at least 6-12 months.Option D (Anterior glenohumeral instability with significant bone loss) is incorrect. The MRI shows no significant bone loss. Latarjet procedure is for recurrent anterior instability with significant glenoid bone loss.Option E (SLAP tear) can cause pain and clicking, but the prominent instability signs (apprehension, sulcus) and generalized laxity point more strongly to MDI as the primary pathology. SLAP tears can coexist but are often secondary to instability or other mechanisms.

Question 2211

Topic: Shoulder & Hip Sports

A 22-year-old female volleyball player presents with recurrent, multidirectional shoulder instability following an anterior dislocation that occurred during an overhead serve. She reports symptoms of apprehension with abduction-external rotation, as well as a positive sulcus sign and generalized ligamentous laxity. MRI shows a Bankart lesion and a small Hills-Sachs lesion. Conservative management with extensive physical therapy has failed. What is the most appropriate surgical approach?

. Open Latarjet procedure.
. Arthroscopic Bankart repair with capsular plication.
. Arthroscopic posterior capsular shift.
. Open inferior capsular shift.
. Arthroscopic Remplissage procedure.

Correct Answer & Explanation

. Arthroscopic Bankart repair with capsular plication.

Explanation

This patient presents with multidirectional instability (MDI) following an anterior dislocation, characterized by symptoms of apprehension with abduction-external rotation (anterior instability), a positive sulcus sign (inferior instability), and generalized ligamentous laxity. The presence of a Bankart and small Hill-Sachs lesion in the context of MDI suggests a complex instability pattern. While an arthroscopic Bankart repair (Option B) addresses the anterior labral pathology, it may not adequately stabilize the inferior and posterior components of MDI, especially with generalized laxity. A capsular plication or shift is typically required for MDI. An open inferior capsular shift (Option D) or arthroscopic equivalent is often considered the gold standard for MDI to reduce capsular volume globally. However, given the primary anterior dislocation and Bankart lesion, addressing the anterior component robustly is crucial. An arthroscopic posterior capsular shift (Option C) addresses posterior laxity but not the dominant anterior component. A Latarjet procedure (Option A), which involves transferring the coracoid process with its attached conjoined tendons to the anterior glenoid, is primarily indicated for significant anterior glenoid bone loss or failed anterior instability repairs, but it provides excellent anterior stability and can be considered in specific MDI cases with anterior emphasis, especially in collision athletes or those with generalized laxity where soft tissue repair alone might fail. In this scenario, with a Bankart lesion and MDI in an overhead athlete, a comprehensive approach addressing both soft tissue and potentially bony components (if recurrence risk is high) is needed. The question implies a challenging scenario and failed conservative management. Arthroscopic Bankart repair with capsular plication (Option B) is the most common approach for MDI with a Bankart. However, the Latarjet procedure is increasingly considered in cases of MDI with a significant anterior component, especially in high-demand overhead athletes with bone loss or generalized laxity, as it offers a more robust stabilization. Given the options, 'Arthroscopic Bankart repair with capsular plication' addresses the main pathologies and is a common approach for MDI.

Question 2212

Topic: Shoulder & Hip Sports

A 28-year-old professional football player suffers a traumatic anterior shoulder dislocation. After successful closed reduction, radiographs reveal a large osseous Bankart lesion involving approximately 25% of the glenoid articular surface, along with a significant Hill-Sachs lesion. This is his first dislocation. What is the most appropriate surgical management to minimize the risk of recurrent instability and allow a safe return to high-level sport?

. Arthroscopic Bankart repair with capsular plication.
. Open Latarjet procedure.
. Arthroscopic Remplissage procedure combined with Bankart repair.
. Non-operative management with extensive physiotherapy.
. Glenoid osteotomy to reconstruct the anterior glenoid rim.

Correct Answer & Explanation

. Open Latarjet procedure.

Explanation

For a professional athlete with a traumatic first-time anterior shoulder dislocation and significant glenoid bone loss (>20-25%), an open Latarjet procedure (Option B) is generally considered the gold standard to restore glenoid bone stock and provide a 'sling effect' for dynamic stability, significantly reducing the risk of recurrence. Arthroscopic Bankart repair (Option A) alone is associated with high failure rates in the presence of significant glenoid bone loss and is insufficient for high-demand athletes with this type of injury. Remplissage (Option C) addresses large Hill-Sachs lesions but does not restore glenoid bone loss. Non-operative management (Option D) is inappropriate for a professional athlete with significant bone loss after a dislocation. Glenoid osteotomy (Option E) is a complex procedure not typically indicated for standard glenoid bone loss from dislocation. Given the 'professional football player' and '25% glenoid loss,' the Latarjet procedure offers the best chance for stability and return to play.

Question 2213

Topic: Shoulder & Hip Sports

In the management of proximal humerus fractures, what is the primary role of reverse total shoulder arthroplasty (rTSA) in an elderly patient with a complex 3- or 4-part fracture?

. To provide anatomical reduction and union of the fracture fragments.
. To preserve the rotator cuff function.
. To improve active elevation in the presence of an irreparable rotator cuff or poor bone quality.
. To reduce the risk of avascular necrosis of the humeral head.
. To allow early, aggressive rehabilitation targeting rotator cuff strengthening.

Correct Answer & Explanation

. To improve active elevation in the presence of an irreparable rotator cuff or poor bone quality.

Explanation

Reverse total shoulder arthroplasty (rTSA) (Option C) is increasingly used for complex 3- or 4-part proximal humerus fractures in elderly patients, especially those with poor bone quality, pre-existing rotator cuff dysfunction, or at high risk for avascular necrosis. Its primary advantage is to improve active elevation by medializing and distalizing the center of rotation, which enhances deltoid leverage, essentially bypassing the need for a functional rotator cuff. It does not aim for anatomical reduction and union of the fracture fragments (Option A) in the traditional sense, as the humeral head is resected. It does not preserve rotator cuff function (Option B); rather, it compensates for it. While it may reduce the risk of AVN (Option D) by replacing the humeral head, its primary functional benefit is to restore active motion. Early, aggressive rehabilitation of the rotator cuff (Option E) is not the goal, as the rTSA's function relies on the deltoid, not the rotator cuff.

Question 2214

Topic: Shoulder & Hip Sports
Following a rotator cuff repair, a patient undergoes rehabilitation. During the early proliferative phase of tendon healing, the newly formed granulation tissue is primarily characterized by an increased synthesis of which type of collagen, before remodeling shifts towards the mature tendon composition?
. Type II collagen
. Type V collagen
. Type III collagen
. Type IX collagen
. Type XI collagen

Correct Answer & Explanation

. Type III collagen

Explanation

During the initial stages of tendon healing (inflammatory and proliferative phases), there is an upregulation of Type III collagen synthesis. Type III collagen forms thinner, more disorganized fibrils compared to the mature Type I collagen. As healing progresses and the tissue remodels, Type III collagen is gradually replaced by Type I collagen, which is the predominant collagen (approximately 90-95%) in healthy, mature tendons, providing tensile strength. Type II, IX, and XI collagens are primarily found in cartilage. Type V collagen is a minor fibrillar collagen that co-polymerizes with Type I and II collagen, important for fibril assembly, but not the primary temporary collagen in healing.

Question 2215

Topic: Shoulder & Hip Sports
The enthesis, the specialized interface where tendons and ligaments attach to bone, varies in its structural complexity. A 'fibrocartilaginous enthesis' is characterized by distinct zones that transition from tendon/ligament to bone. Which sequence correctly describes these zones, moving from the tendon/ligament into the bone?
. Collagen fibers β†’ Mineralized fibrocartilage β†’ Unmineralized fibrocartilage β†’ Bone
. Tendon/Ligament β†’ Unmineralized fibrocartilage β†’ Mineralized fibrocartilage β†’ Bone
. Tendon/Ligament β†’ Mineralized fibrocartilage β†’ Unmineralized fibrocartilage β†’ Bone β†’ Cement line
. Collagen fibers β†’ Bone β†’ Unmineralized fibrocartilage β†’ Mineralized fibrocartilage
. Tendon/Ligament β†’ Sharpey's fibers β†’ Bone β†’ Marrow

Correct Answer & Explanation

. Tendon/Ligament β†’ Unmineralized fibrocartilage β†’ Mineralized fibrocartilage β†’ Bone

Explanation

A fibrocartilaginous enthesis, typical for high-load attachments (e.g., rotator cuff tendons, Achilles tendon), consists of four distinct zones: 1) Tendon/Ligament proper (dense fibrous connective tissue), 2) Unmineralized fibrocartilage, 3) Mineralized fibrocartilage (separated from unmineralized by a 'tidemark'), and 4) Bone. This gradual transition helps dissipate stress and prevent acute stress concentrations at the bone-tendon interface. Option B correctly represents this four-zone transition. Options A, C, D, and E are incorrect sequences or omit critical zones/details.

Question 2216

Topic: Shoulder & Hip Sports

A 24-year-old collegiate hockey player presents with persistent anterior groin pain exacerbated by hip flexion and internal rotation. Radiographs demonstrate an alpha angle of 72 degrees on the Dunn view.

Which of the following best describes the primary pathomechanical pattern of chondral damage associated with this morphology?

. Global full-thickness chondrolysis of the femoral head
. Contrecoup cartilage lesions in the posteroinferior acetabulum due to levering
. Delamination of the anterosuperior acetabular cartilage due to outside-in shear forces
. Crushing of the labrum with secondary ossification of the acetabular rim
. Ligamentum teres avulsion leading to medial joint space narrowing

Correct Answer & Explanation

. Delamination of the anterosuperior acetabular cartilage due to outside-in shear forces

Explanation

An alpha angle > 55 degrees indicates Cam-type femoroacetabular impingement (FAI). Cam morphology causes outside-in shear forces against the anterosuperior acetabular rim during hip flexion and internal rotation. This selectively damages the transitional zone cartilage, causing delamination of the articular cartilage off the subchondral bone while often leaving the labrum initially intact. Pincer impingement typically causes labral crushing and contrecoup chondral lesions.

Question 2217

Topic: Shoulder & Hip Sports

During arthroscopic evaluation of the shoulder for an overhead athlete, the surgeon encounters an isolated, full-thickness tear of the subscapularis tendon.

The 'comma sign' is prominently observed. What specific anatomic structures compose this arthroscopic landmark?

. The coracoacromial ligament and the long head of the biceps tendon
. The medial edge of the supraspinatus tendon retracting from the greater tuberosity
. The superior glenohumeral ligament (SGHL) and the coracohumeral ligament (CHL)
. The middle glenohumeral ligament (MGHL) and the inferior glenohumeral ligament (IGHL) complex
. The transverse humeral ligament and the superior labrum

Correct Answer & Explanation

. The superior glenohumeral ligament (SGHL) and the coracohumeral ligament (CHL)

Explanation

The 'comma sign' is a highly reliable arthroscopic indicator of a subscapularis tear. It is formed by the superior glenohumeral ligament (SGHL) and the coracohumeral ligament (CHL), which avulse from their attachments on the lesser tuberosity and retract medially with the superolateral corner of the torn subscapularis tendon, creating a comma-shaped tissue band.

Question 2218

Topic: Shoulder & Hip Sports

A 25-year-old tennis player presents with posterior shoulder pain during the cocking phase of serving. Exam shows profound Glenohumeral Internal Rotation Deficit (GIRD). MR arthrogram shows articular-sided fraying of the posterior supraspinatus.

What is the primary underlying pathomechanism for internal impingement in this athlete?

. Subacromial spurring causing bursal-sided cuff tearing
. Posteroinferior capsular contracture leading to obligate posterosuperior shift of the humeral head in maximal external rotation
. Anterior capsular laxity resulting in obligate anteroinferior subluxation during external rotation
. Hypertrophy of the coracoacromial ligament impinging the subscapularis
. Congenital glenoid retroversion causing dynamic instability

Correct Answer & Explanation

. Posteroinferior capsular contracture leading to obligate posterosuperior shift of the humeral head in maximal external rotation

Explanation

Internal impingement is primarily caused by a posteroinferior capsular contracture (associated with GIRD) which creates a dynamic tether. When the arm is brought into maximal abduction and external rotation (late cocking phase), this tether forces an obligate posterosuperior shift of the humeral head, pinching the posterosuperior labrum and the articular surface of the supraspinatus/infraspinatus.

Question 2219

Topic: Shoulder & Hip Sports

A 29-year-old overhead athlete presents with vague posterior shoulder pain, weakness in external rotation, and no sensory deficits. MRI reveals isolated atrophy and fatty infiltration of the teres minor.

The neurovascular structure most likely compressed in this condition exits through an anatomical space. Which of the following defines the borders of this space?

. Teres minor (superior), teres major (inferior), long head of triceps (medial), humeral shaft (lateral)
. Teres major (superior), latissimus dorsi (inferior), long head of triceps (lateral), short head of biceps (medial)
. Teres minor (superior), teres major (inferior), long head of triceps (lateral), humeral shaft (medial)
. Supraspinatus (superior), infraspinatus (inferior), spine of scapula (medial), glenoid neck (lateral)
. Subscapularis (superior), teres major (inferior), coracobrachialis (lateral), rib cage (medial)

Correct Answer & Explanation

. Teres minor (superior), teres major (inferior), long head of triceps (lateral), humeral shaft (medial)

Explanation

The patient has Quadrilateral Space Syndrome, causing compression of the axillary nerve and posterior circumflex humeral artery. This leads to isolated teres minor atrophy. The quadrilateral space is bordered by the teres minor (superior), teres major (inferior), long head of the triceps (medial), and surgical neck of the humerus (lateral).

Question 2220

Topic: Shoulder & Hip Sports

A 28-year-old female presents with lateral 'snapping' of the hip when walking and ascending stairs. The snap is palpable over the greater trochanter and reproduced when moving the hip from flexion to extension. A diagnosis of external snapping hip syndrome is made. If conservative management fails, surgical release of which structure is most indicated?

. Iliopsoas tendon
. Iliotibial (IT) band
. Rectus femoris
. Gluteus medius tendon
. Ligamentum teres

Correct Answer & Explanation

. Iliotibial (IT) band

Explanation

External snapping hip (coxa saltans externa) is caused by the iliotibial (IT) band or the anterior border of the gluteus maximus snapping over the greater trochanter during hip flexion and extension. Internal snapping hip is caused by the iliopsoas tendon snapping over the iliopectineal eminence or the femoral head.

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