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Shoulder & Hip Sports MCQs

Practice Set 12 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 221

Topic: Shoulder & Hip Sports

A surgeon is performing a revision total shoulder arthroplasty via the deltopectoral approach on a patient with a failed glenoid component. After mobilizing the subscapularis, the surgeon needs to achieve maximal exposure of the glenoid. Which of the following maneuvers, if performed excessively, carries the highest risk of injury to the axillary neurovascular bundle?

. A. Excessive superior retraction of the deltoid muscle.
. B. Aggressive medial retraction of the conjoined tendon and pectoralis minor.
. C. Extensive lateral retraction of the pectoralis major muscle.
. D. Deep dissection along the lateral aspect of the humeral shaft.
. E. Vigorous inferior retraction of the humeral head.

Correct Answer & Explanation

. B. Aggressive medial retraction of the conjoined tendon and pectoralis minor.

Explanation

Correct Answer: BThe case study explicitly warns about the axillary neurovascular bundle: 'Situated medial and deep to the coracoid process. This bundle contains the axillary artery, axillary vein, and brachial plexus cords (lateral, posterior, medial). Retraction of the conjoined tendon medially allows access to the subscapularis, but extreme medial retraction risks injury to this bundle.' Therefore, aggressive medial retraction of the conjoined tendon and pectoralis minor directly threatens the axillary neurovascular bundle. Option A (superior deltoid retraction) is less likely to injure the main axillary bundle, though the axillary nerve's anterior branch could be at risk. Option C (lateral pectoralis major retraction) is not the primary direction of risk for the axillary bundle. Option D (lateral humeral shaft dissection) is too distal and lateral to directly impact the axillary bundle. Option E (inferior humeral head retraction) could put the axillary nerve at risk as it wraps around the surgical neck, but the question specifically asks about the 'axillary neurovascular bundle' which is more medial and deep, and directly threatened by medial retraction of the conjoined tendon and pectoralis minor.

Question 222

Topic: Shoulder & Hip Sports

During an anatomic total shoulder arthroplasty, the surgeon elects to perform a lesser tuberosity osteotomy (LTO) rather than a subscapularis tenotomy. Based on current literature, what is the primary advantage of the LTO technique compared to tenotomy?

. Decreased risk of axillary nerve injury.
. Shorter operative time and simpler surgical exposure.
. Lower rate of postoperative anterior instability.
. Improved structural healing rates via bone-to-bone healing and better postoperative subscapularis strength.
. Elimination of the need for postoperative sling immobilization.

Correct Answer & Explanation

. Improved structural healing rates via bone-to-bone healing and better postoperative subscapularis strength.

Explanation

A lesser tuberosity osteotomy allows for bone-to-bone healing of the subscapularis insertion, which has been shown in multiple studies to result in higher rates of structural healing on ultrasound and improved postoperative subscapularis strength compared to a soft-tissue tenotomy.

Question 223

Topic: Shoulder & Hip Sports

A 70-year-old, right-hand-dominant woman presents with chronic right shoulder pain and weakness, unable to reach overhead. Physical examination reveals significant atrophy of the supraspinatus and infraspinatus, limited active range of motion, and positive drop arm and external rotation lag signs. MRI confirms a massive rotator cuff tear involving the supraspinatus and infraspinatus, with minimal atrophy, minimal fatty infiltration, and retraction to the glenoid. Given these findings, which of the following best describes the initial Goutallier classification of her rotator cuff tear?

. Stage 0
. Stage 1
. Stage 2
. Stage 3
. Stage 4

Correct Answer & Explanation

. Stage 2

Explanation

Correct Answer: CThe patient's MRI shows 'minimal atrophy, minimal fatty infiltration, and retraction to the glenoid' for both the supraspinatus and infraspinatus. According to the Goutallier classification system, which assesses fatty degeneration of the rotator cuff muscles, Stage 0 is normal, Stage 1 is minimal fatty streaks, Stage 2 is a significant amount of fatty streaks but more muscle than fat, Stage 3 is equal amounts of fat and muscle, and Stage 4 is more fat than muscle. The description 'minimal fatty infiltration' aligns most closely with Stage 2, where there are significant fatty streaks but still more muscle than fat. Stage 3 (equal fat and muscle) and Stage 4 (more fat than muscle) would imply more significant fatty infiltration, which is not indicated by 'minimal'. The image (Figure 2-18) visually demonstrates these stages, with Stage 2 showing clear muscle bulk with some interspersed fat, consistent with 'minimal fatty infiltration' compared to the more severe Stage 3 and 4 examples.

Question 224

Topic: Shoulder & Hip Sports

During arthroscopy for a massive, immobile rotator cuff tear, it is confirmed that a small part of the anterior supraspinatus remains attached to the greater tuberosity laterally, and the rotator interval is intact anteriorly. The surgeon plans to mobilize the tear to allow for repair to the greater tuberosity, followed by marginal convergence. Which specific technique is indicated to facilitate the initial mobilization of this tear?

. Posterior interval slide
. Krackow stitch
. Anterior interval slide
. Double-bundle reconstruction
. Subscapularis release

Correct Answer & Explanation

. Anterior interval slide

Explanation

Correct Answer: CThe case describes a scenario where a small part of the anterior supraspinatus is still attached to the greater tuberosity laterally and the rotator interval is intact anteriorly. The discussion explicitly states that in an anterior interval slide technique, 'there is some anterior portion of the supraspinatus still attached to the greater tuberosity laterally and rotator interval anteriorly. The greater tuberosity attachment can be incised and the rotator interval attachment can be detached by incising the coracohumeral ligament.' This technique decreases tension and improves lateral mobilization, allowing the supraspinatus to be more easily repaired. The image (Figure 2-16) illustrates this process, showing the incision of the rotator interval and coracohumeral ligament to mobilize the anterior supraspinatus. A posterior interval slide (Option A) is used when the posterior supraspinatus is attached to the infraspinatus. A Krackow stitch (Option B) is a locking stitch for tendinous repairs, not a mobilization technique for rotator cuff tears. Double-bundle reconstruction (Option D) is an ACL reconstruction technique. Subscapularis release (Option E) is not described as a primary mobilization technique for supraspinatus tears in this context.

Question 225

Topic: Shoulder & Hip Sports

A 50-year-old, healthy, active patient presents with a massive, irreparable rotator cuff tear involving the supraspinatus and infraspinatus, similar to the initial case, but without any signs of glenohumeral arthritis. He has failed extensive conservative management. Which of the following is the most appropriate surgical treatment option to restore function?

. Arthroscopic rotator cuff repair
. Subscapularis tendon transfer
. Latissimus dorsi tendon transfer
. Trapezius tendon transfer
. Reverse total shoulder arthroplasty

Correct Answer & Explanation

. Latissimus dorsi tendon transfer

Explanation

Correct Answer: CFor young, active patients (like this 50-year-old) with a massive, irreparable rotator cuff tear involving the supraspinatus and infraspinatus, but without glenohumeral arthritis, a tendon transfer is the most reasonable option to restore function. The discussion specifically highlights the latissimus dorsi tendon transfer as the most popular way to restore the posterior and inferior force-couples and create an external rotation force in such cases. The image (Figure 2-19) illustrates the latissimus dorsi tendon transfer. Arthroscopic rotator cuff repair (Option A) is not indicated for an irreparable tear with significant fatty degeneration. Subscapularis tendon transfer (Option B) would not address the loss of the posterior and inferior force-couple from the torn infraspinatus. Trapezius tendon transfer (Option D) is mentioned as having some interest but is not as popular or well-established for rotator cuff tears as the latissimus dorsi transfer, and often requires allograft. Reverse total shoulder arthroplasty (Option E) is generally reserved for older, less active patients or those with cuff tear arthropathy, as it has limitations in lifting activities and a higher revision risk in younger patients.

Question 226

Topic: Shoulder & Hip Sports

A patient is diagnosed with a chronic, irreparable tear of the subscapularis tendon after failing conservative treatment. The surgeon plans a tendon transfer to restore internal rotation and humeral head centering. Which of the following tendons is the most reasonable choice for transfer in this scenario?

. Subscapularis tendon repair
. Biceps tenotomy
. Pectoralis major tendon transfer
. Reverse total shoulder arthroplasty
. Supraspinatus tendon transfer

Correct Answer & Explanation

. Pectoralis major tendon transfer

Explanation

Correct Answer: CFor a chronic, irreparable tear of the subscapularis tendon, the discussion states that using a tendon transfer is the next step. The pectoralis major tendon is highlighted as an effective choice because its force vector is similar to that of the subscapularis, allowing it to restore internal rotation and humeral head centering and compression. The surgery involves detaching the pectoralis major from its humeral insertion and moving it to the lesser tuberosity. The image (Figure 2-20) depicts the pectoralis major tendon transfer. Subscapularis tendon repair (Option A) is impossible by definition if the tear is irreparable. Biceps tenotomy (Option B) might be performed adjunctively but does not restore subscapularis function. Reverse total shoulder arthroplasty (Option D) is typically used for massive, irreparable anterosuperior rotator cuff tears, not isolated subscapularis tears. Supraspinatus tendon transfer (Option E) is not a described procedure for irreparable subscapularis tears.

Question 227

Topic: Shoulder & Hip Sports

A 60-year-old patient presents with a chronic, U-shaped rotator cuff tear that is retracted to the glenoid. The surgeon determines that the apex of the tear cannot be mobilized to the greater tuberosity. Which repair technique is most appropriate to convert this tear into a reparable configuration?

. Anterior interval slide
. Posterior interval slide
. Crescent repair
. Marginal convergence
. Double-row repair

Correct Answer & Explanation

. Marginal convergence

Explanation

Correct Answer: DThe case discussion specifically addresses U-shaped tears, stating that 'U-shaped tears have an apex that extends further medially... and this part cannot be mobilized all the way to the greater tuberosity. Because of this lack of mobility, these tears have to be repaired using marginal convergence, which is essentially zipping up the U from the apex toward the greater tuberosity using side to side sutures to bring together the anterior and posterior leaves of the U-shaped tear. In performing this marginal convergence, you essentially are converting a U-shaped tear into a crescent-shaped tear that can be relatively easily mobilized to the greater tuberosity, allowing it to be repaired.' The image (Figure 2-14) clearly illustrates this process. Anterior (Option A) and posterior (Option B) interval slides are used for massive, immobile tears with specific attachments, not primarily for U-shaped tears that are retracted to the glenoid apex. Crescent repair (Option C) is the final repair type after conversion, not the conversion technique itself. Double-row repair (Option E) is a method of fixation to bone, not a technique to mobilize or convert tear shape.

Question 228

Topic: Shoulder & Hip Sports

A 68-year-old male presents with chronic shoulder pain and weakness. MRI demonstrates a massive, retracted tear of the supraspinatus and infraspinatus tendons. The T1-weighted sagittal oblique images show that there is more fat than muscle tissue within the infraspinatus muscle belly. What Goutallier stage does this represent?

. Stage 1
. Stage 2
. Stage 3
. Stage 4
. Stage 5

Correct Answer & Explanation

. Stage 3

Explanation

In the Goutallier classification for fatty infiltration, Stage 3 indicates equal amounts of fat and muscle, while Stage 4 indicates more fat than muscle. Advanced fatty infiltration (Stages 3 and 4) is generally considered a contraindication to primary rotator cuff repair.

Question 229

Topic: Shoulder & Hip Sports

During dynamic stabilization of the glenohumeral joint, the transverse force couple is essential for maintaining the humeral head centered on the glenoid. Which muscle groups primarily constitute this anterior-posterior transverse force couple?

. Supraspinatus and Deltoid
. Subscapularis and Infraspinatus/Teres minor
. Pectoralis major and Latissimus dorsi
. Coracobrachialis and short head of the Biceps
. Rhomboids and Serratus anterior

Correct Answer & Explanation

. Subscapularis and Infraspinatus/Teres minor

Explanation

The transverse (axial) force couple of the shoulder consists of the subscapularis anteriorly and the infraspinatus and teres minor posteriorly. Intact function of this force couple is required to compress the humeral head into the glenoid and prevent superior escape.

Question 230

Topic: Shoulder & Hip Sports

A 45-year-old heavy laborer presents with a massive, irreparable posterosuperior rotator cuff tear. He has persistent pain and lack of active external rotation, but his subscapularis is fully intact and he lacks glenohumeral arthritis. Which of the following tendon transfers is most appropriate to restore external rotation and function in this patient?

. Pectoralis major transfer
. Latissimus dorsi transfer
. Lower trapezius transfer
. Levator scapulae transfer
. Rhomboid major transfer

Correct Answer & Explanation

. Lower trapezius transfer

Explanation

For an active, younger patient with an irreparable posterosuperior rotator cuff tear (supraspinatus/infraspinatus) and an intact subscapularis, a lower trapezius transfer is highly effective. Its line of pull closely replicates that of the infraspinatus, restoring active external rotation.

Question 231

Topic: Shoulder & Hip Sports

A 60-year-old male is evaluated for a massive, retracted rotator cuff tear. An MRI reveals Goutallier Stage 4 fatty infiltration of the infraspinatus. How is Goutallier Stage 4 defined on imaging?

. Some fatty streaks within the muscle belly
. More muscle than fat
. Equal amounts of muscle and fat
. More fat than muscle
. Complete absence of muscle tissue

Correct Answer & Explanation

. Equal amounts of muscle and fat

Explanation

The Goutallier classification grades fatty infiltration of the rotator cuff. Stage 3 is defined as equal amounts of fat and muscle, while Stage 4 is defined as more fat than muscle, indicating a high likelihood of structural failure if repaired.

Question 232

Topic: Shoulder & Hip Sports

During arthroscopic evaluation of a massive rotator cuff tear, the surgeon identifies the 'comma sign'. This anatomical landmark is formed by the avulsion and retraction of which structures?

. Superior labrum and biceps tendon
. Superior glenohumeral ligament (SGHL) and coracohumeral ligament (CHL)
. Middle glenohumeral ligament (MGHL) and subscapularis tendon
. Coracoacromial ligament and short head of the biceps
. Inferior glenohumeral ligament (IGHL) and posterior band

Correct Answer & Explanation

. Superior glenohumeral ligament (SGHL) and coracohumeral ligament (CHL)

Explanation

The 'comma sign' is a vital arthroscopic landmark seen with subscapularis tears. It represents the avulsed complex of the superior glenohumeral ligament (SGHL) and the coracohumeral ligament (CHL) retracting medially and inferiorly.

Question 233

Topic: Shoulder & Hip Sports

A 45-year-old overhead athlete presents with persistent shoulder pain. MRI reveals a Partial Articular-Sided Tendon Avulsion (PASTA) of the supraspinatus. At what depth of footprint involvement is surgical completion and repair generally indicated?

. Greater than 10%
. Greater than 25%
. Greater than 50%
. Only if it extends into the bursal surface
. Only if it involves the infraspinatus

Correct Answer & Explanation

. Greater than 50%

Explanation

Partial articular-sided rotator cuff tears involving greater than 50% of the tendon thickness (roughly 6-7 mm of the medial-to-lateral footprint) are typically treated with completion of the tear and repair, or in-situ repair, due to poor healing potential with debridement alone.

Question 234

Topic: Shoulder & Hip Sports

A 68-year-old male is 6 weeks status-post anatomic total shoulder arthroplasty via a deltopectoral approach. He complains of sudden anterior shoulder pain and weakness after reaching out for a door. Exam shows a positive belly-press test and increased passive external rotation compared to his immediate postoperative records. What is the most likely complication?

. Deltoid dehiscence
. Subscapularis failure
. Anterior glenoid component loosening
. Axillary nerve palsy
. Infraspinatus rupture

Correct Answer & Explanation

. Subscapularis failure

Explanation

Subscapularis failure following anatomic TSA typically presents with anterior pain, weakness in internal rotation (positive belly-press/bear-hug), and increased passive external rotation. It is a known complication related to the takedown and repair of the tendon during the deltopectoral approach.

Question 235

Topic: Shoulder & Hip Sports

A 48-year-old male presents with shoulder pain. MRI shows a full-thickness supraspinatus tear and a cyst at the spinoglenoid notch. Which physical examination finding is most likely to be present?

. Weakness in forward elevation only
. Weakness in internal rotation
. Isolated weakness in external rotation with the arm at the side
. Loss of sensation over the lateral deltoid
. Weakness in both external rotation and abduction

Correct Answer & Explanation

. Isolated weakness in external rotation with the arm at the side

Explanation

A cyst at the spinoglenoid notch classically compresses the suprascapular nerve after it has innervated the supraspinatus, leading to isolated denervation of the infraspinatus. This presents clinically as isolated weakness in external rotation.

Question 236

Topic: Shoulder & Hip Sports

During an arthroscopic rotator cuff repair, the surgeon evaluates the footprint of the torn tendons. Which of the following accurately describes the anatomic footprint of the infraspinatus tendon on the greater tuberosity?

. It inserts onto the superior facet and is the largest component of the footprint
. It inserts onto the middle facet and occupies the majority of the greater tuberosity footprint
. It inserts onto the inferior facet and blends with the teres minor
. It inserts onto the lesser tuberosity
. It inserts onto the bicipital groove

Correct Answer & Explanation

. It inserts onto the middle facet and occupies the majority of the greater tuberosity footprint

Explanation

Anatomic studies show the infraspinatus inserts onto the middle facet and wraps anteriorly, occupying a much larger portion of the greater tuberosity footprint than historically recognized. The supraspinatus insertion is smaller and localized to the anteromedial aspect of the superior facet.

Question 237

Topic: Shoulder & Hip Sports

A 28-year-old professional volleyball player complains of vague posterior shoulder pain and weakness with external rotation. Examination reveals isolated atrophy of the infraspinatus fossa. An MRI demonstrates a paralabral cyst. At which of the following anatomical locations is the nerve compression most likely occurring?

. Suprascapular notch
. Spinoglenoid notch
. Quadrilateral space
. Triangular interval
. Spiral groove

Correct Answer & Explanation

. Spinoglenoid notch

Explanation

Compression of the suprascapular nerve at the spinoglenoid notch results in isolated denervation of the infraspinatus muscle. Compression at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 238

Topic: Shoulder & Hip Sports

A 65-year-old man presents with chronic right shoulder pain and weakness. On physical examination, he has full passive range of motion. When his arm is passively abducted to 90 degrees and externally rotated to 90 degrees, the examiner releases the arm and the patient is unable to maintain the externally rotated position, causing the arm to drop into internal rotation. Which of the following muscles is most likely deficient, and what is its primary innervation?

. Infraspinatus; Suprascapular nerve
. Subscapularis; Upper and Lower subscapular nerves
. Teres minor; Axillary nerve
. Supraspinatus; Suprascapular nerve
. Teres major; Lower subscapular nerve

Correct Answer & Explanation

. Teres minor; Axillary nerve

Explanation

The test described is the Hornblower's sign, which is highly specific for evaluating the teres minor. The teres minor acts as an external rotator in 90 degrees of abduction and is innervated by the axillary nerve.

Question 239

Topic: Shoulder & Hip Sports

A 55-year-old manual laborer presents with chronic shoulder pain and weakness. MRI reveals a massive, retracted, and fatty-infiltrated tear of the supraspinatus and infraspinatus. His subscapularis is completely intact. Clinically, he has intact active forward elevation but a positive drop sign and severe external rotation lag. There is no evidence of glenohumeral osteoarthritis. Which of the following surgical procedures is most appropriate to restore his external rotation?

. Pectoralis major tendon transfer.
. Latissimus dorsi tendon transfer.
. Subscapularis tendon advancement.
. Biceps tenodesis and subacromial decompression.
. Reverse total shoulder arthroplasty.

Correct Answer & Explanation

. Latissimus dorsi tendon transfer.

Explanation

In a younger laborer with an irreparable posterosuperior rotator cuff tear (supraspinatus/infraspinatus) but an intact subscapularis and preserved forward elevation, a latissimus dorsi or lower trapezius transfer is indicated to restore active external rotation. Pectoralis major transfers are reserved for irreparable subscapularis tears.

Question 240

Topic: Shoulder & Hip Sports

A 48-year-old woman is evaluated for right shoulder pain after a fall. The orthopaedic surgeon asks the patient to place the palm of her right hand on her left shoulder with her elbow pointing forward. The surgeon then attempts to pull the patient's hand off the shoulder while instructing the patient to resist. The patient is unable to keep her hand pressed against the shoulder. This physical examination finding is most indicative of a tear in which of the following structures?

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

Correct Answer & Explanation

. Subscapularis tendon

Explanation

The maneuver described is the "Bear Hug" test. It is a highly sensitive and specific clinical examination tool used to detect insufficiency or tearing of the subscapularis tendon.

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