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 301
Topic: Shoulder & Hip Sports
A 35-year-old professional volleyball player presents with isolated weakness in shoulder external rotation. Supraspinatus strength is normal on empty-can testing. Inspection reveals prominent atrophy limited to the infraspinatus fossa. Where is the most likely anatomic location of nerve entrapment?
Correct Answer & Explanation
. Spinoglenoid notch
Explanation
The suprascapular nerve innervates both the supraspinatus and infraspinatus. Entrapment at the spinoglenoid notch affects only the branch to the infraspinatus, causing isolated external rotation weakness and isolated infraspinatus atrophy.
Question 302
Topic: Shoulder & Hip Sports
A 50-year-old male sustains a forced external rotation injury to his shoulder. He presents with increased passive external rotation and a positive belly-press test. MRI confirms an isolated, full-thickness retraction of the subscapularis tendon. Which associated anatomic structure is at the highest risk of concomitant instability or injury?
Correct Answer & Explanation
. Long head of the biceps tendon
Explanation
The subscapularis tendon insertion forms a critical portion of the biceps sling (transverse humeral ligament complex). A full-thickness, retracted subscapularis tear frequently leads to medial subluxation or dislocation of the long head of the biceps tendon.
Question 303
Topic: Shoulder & Hip Sports
A 21-year-old collegiate rugby player presents with recurrent anterior shoulder instability. A CT scan of the shoulder reveals 25% anterior glenoid bone loss. Which of the following is the most appropriate surgical intervention?
Correct Answer & Explanation
. Latarjet procedure
Explanation
The Latarjet procedure is indicated for recurrent anterior shoulder instability in the setting of critical anterior glenoid bone loss (typically >20-25%). Arthroscopic soft tissue stabilization has an unacceptably high failure rate in patients with significant bone loss.
Question 304
Topic: Shoulder & Hip Sports
A 40-year-old male presents with a locked, internally rotated right shoulder following a generalized seizure. Imaging confirms a posterior shoulder dislocation with a 30% reverse Hill-Sachs lesion. Which of the following is the most appropriate surgical management?
Correct Answer & Explanation
. Transfer of the lesser tuberosity into the defect (McLaughlin procedure)
Explanation
A reverse Hill-Sachs lesion is an impaction fracture of the anteromedial humeral head following a posterior dislocation. For defects between 20% and 40%, transfer of the lesser tuberosity or subscapularis tendon into the defect (McLaughlin procedure) is the preferred treatment.
Question 305
Topic: Shoulder & Hip Sports
A 22-year-old male collegiate football player presents with recurrent anterior shoulder instability. A 3D CT scan of the shoulder reveals 25% anterior glenoid bone loss. Which of the following surgical interventions is most appropriate to minimize recurrence?
Correct Answer & Explanation
. Coracoid transfer to the anterior glenoid (Latarjet)
Explanation
In collision athletes with critical anterior glenoid bone loss (>20-25%), an arthroscopic Bankart repair has an unacceptably high failure rate. The Latarjet procedure (coracoid transfer) addresses the bony defect and provides a sling effect to stabilize the joint.
Question 306
Topic: Shoulder & Hip Sports
A 22-year-old collegiate rugby player presents with recurrent anterior shoulder instability. A 3D CT scan reveals 27% anterior glenoid bone loss. An MRI confirms a concomitant Hill-Sachs lesion, and the lesion is determined to be "off-track." Which of the following is the most appropriate definitive surgical management?
Correct Answer & Explanation
. Coracoid process transfer (Latarjet procedure)
Explanation
In the setting of significant anterior glenoid bone loss (>20-25%), isolated soft tissue repairs have an unacceptably high failure rate. A coracoid transfer (Latarjet) reconstructs the bony defect and provides a dynamic sling via the conjoint tendon.
Question 307
Topic: Shoulder & Hip Sports
A 28-year-old elite volleyball attacker presents with vague posterior shoulder pain and isolated weakness in external rotation. Physical examination reveals prominent atrophy of the infraspinatus fossa, while the supraspinatus bulk is normal. Which of the following anatomic structures is the most likely site of pathology?
Correct Answer & Explanation
. Spinoglenoid notch
Explanation
Isolated atrophy and weakness of the infraspinatus indicates compression of the suprascapular nerve at the spinoglenoid notch. Compression at the more proximal suprascapular notch would affect both the supraspinatus and infraspinatus.
Question 308
Topic: Shoulder & Hip Sports
A 45-year-old male presents with acute anterior shoulder pain and weakness after attempting to break a fall with his arm extended and externally rotated. On examination, he exhibits a positive lift-off test and increased passive external rotation compared to the contralateral side. Which tendon is most likely ruptured?
Correct Answer & Explanation
. Subscapularis
Explanation
The subscapularis is the primary internal rotator of the shoulder. A positive lift-off test, belly-press test, and increased passive external rotation are classic physical exam findings for a subscapularis tear.
Question 309
Topic: Shoulder & Hip Sports
During an orthopedic structured oral examination (viva), a candidate rapidly identifies a 'lightbulb sign' on a shoulder radiograph and diagnoses a posterior dislocation, completely missing a subtle reverse Hill-Sachs lesion. This cognitive error, where the examiner stops searching for further abnormalities once an initial finding is made, is known as:
Correct Answer & Explanation
. Satisfaction of search
Explanation
Satisfaction of search is a common perceptual error in radiology and clinical assessments where the observer stops looking for additional, potentially critical findings after discovering the first abnormality. Recognizing this error is a key component of clinical reasoning and viva preparation.
Question 310
Topic: Shoulder & Hip Sports
A 28-year-old male presents with his third episode of anterior glenohumeral dislocation. Initial imaging in the emergency department confirms the dislocation. Given the patient's history and the provided radiograph, which of the following is the most appropriate next step in diagnostic evaluation after successful reduction?
Correct Answer & Explanation
. Order a non-contrast Computed Tomography (CT) scan with 3D reconstructions.
Explanation
Correct Answer: CExplanation:The patient's history of recurrent anterior glenohumeral dislocations (third episode in 18 months) and the mechanism of injury (high-energy fall during rugby with arm abducted and externally rotated) strongly suggest significant underlying structural damage, particularly bipolar bone loss (Hill-Sachs lesion and anterior glenoid bone loss). The initial AP radiograph confirms the dislocation but is insufficient for quantifying these osseous defects.Option C (Order a non-contrast Computed Tomography (CT) scan with 3D reconstructions)is the correct answer. The case explicitly states that 'non-contrast Computed Tomography (CT) with 3D reconstructions is the gold standard for evaluating osseous architecture' and is essential for 'quantifying bipolar bone loss' and 'accurate preoperative planning.' This advanced imaging is crucial to determine the extent of glenoid bone loss and the Hill-Sachs lesion, which dictates the appropriate surgical strategy (e.g., Bankart, Remplissage, Latarjet).Option A (Immediate referral for physical therapy to initiate rotator cuff strengthening)is premature and potentially harmful. While rehabilitation is critical post-operatively, without addressing the underlying structural instability, rotator cuff strengthening alone is unlikely to prevent recurrence in a patient with significant bone loss and recurrent dislocations.Option B (Obtain a stress radiograph series to assess for ligamentous laxity)is not the primary diagnostic step for recurrent instability with suspected bone loss. While ligamentous laxity can contribute, the immediate concern in this case is osseous deficiency, which stress radiographs do not adequately evaluate.Option D (Proceed directly to arthroscopic Bankart repair planning)is incorrect because the type of surgical repair depends entirely on the quantification of bone loss. An isolated Bankart repair would likely fail if critical glenoid bone loss or an 'off-track' Hill-Sachs lesion is present, as highlighted in the case.Option E (Prescribe a sling for 6 weeks with strict immobilization)represents non-operative management, which is explicitly contraindicated for recurrent instability with significant bone loss, especially in a young, competitive contact athlete. The case states, 'Recurrent instability with significant bone loss' is a contraindication for non-operative management.
Question 311
Topic: Shoulder & Hip Sports
Following successful reduction and initial radiographs, a CT scan with 3D reconstructions is obtained for the 28-year-old rugby player. The CT scan, as depicted, reveals significant anterior glenoid bone loss. Based on the case description and the image, which method is widely employed to measure anterior glenoid bone loss on en face 3D CT views?
Correct Answer & Explanation
. The Pico method, drawing a best-fit circle over the inferior portion of the intact glenoid.
Explanation
Correct Answer: CExplanation:Accurate quantification of glenoid bone loss is critical for surgical decision-making in recurrent anterior shoulder instability.Option C (The Pico method, drawing a best-fit circle over the inferior portion of the intact glenoid)is the correct answer. The case explicitly states, 'The Pico method is widely employed to measure anterior glenoid bone loss on en face 3D CT views. A best-fit circle is drawn over the inferior portion of the intact glenoid (or the contralateral normal glenoid for comparison), and the area or width of the missing anterior bone is calculated as a percentage of the total circle.' This method provides a quantitative assessment of the bone defect.Option A (The Sugaya method, measuring the glenoid width on an axial MRI slice)is a method for assessing glenoid bone loss, but it is typically performed on MRI and measures the width, not necessarily the area based on a best-fit circle as described for the Pico method on CT. The case specifically mentions the Pico method for 3D CT.Option B (The Hill-Sachs interval measurement on a sagittal CT view)is used to quantify the Hill-Sachs lesion itself and its relationship to the glenoid, not primarily for measuring anterior glenoid bone loss.Option D (The glenoid track calculation, assessing the engagement of the Hill-Sachs lesion)is a biomechanical concept that integrates both glenoid bone loss and the Hill-Sachs lesion to determine if the Hill-Sachs lesion is 'on-track' or 'off-track.' While crucial for decision-making, it is not a direct method for measuring the anterior glenoid bone loss percentage itself.Option E (The 'inverted pear' sign, qualitatively assessing the glenoid shape)is a qualitative description of significant glenoid bone loss, where the normal pear shape of the glenoid becomes inverted due to erosion of the anterior-inferior aspect. While a relevant concept, it is a qualitative observation rather than a quantitative measurement method like the Pico method.
Question 312
Topic: Shoulder & Hip Sports
The 28-year-old rugby player is found to have critical glenoid bone loss (>15%) and an 'off-track' Hill-Sachs lesion. An open Latarjet procedure is planned. During the procedure, the coracoid graft is being fixed to the anterior glenoid. Which of the following statements regarding the critical technical aspects of graft positioning and fixation is most accurate?
Correct Answer & Explanation
. The graft should be positioned flush with, or slightly medial (1-2 mm) to, the articular cartilage of the anterior glenoid rim.
Explanation
Correct Answer: C. The Latarjet procedure requires meticulous technique to achieve stability and prevent complications. Option C is the correct answer. The case explicitly states, 'The prepared coracoid graft is passed through the subscapularis split. It is positioned flush with, or slightly medial (1-2 mm) to, the articular cartilage of the anterior glenoid rim.' This precise positioning is crucial to restore the glenoid arc without causing iatrogenic osteoarthritis. Option A is incorrect. The case warns, 'Positioning the graft lateral to the cartilage risks severe osteoarthritis.' While a blocking effect is desired, it must be achieved without encroaching on the articular surface. Option B is incorrect. The case states, 'Two 3.75 mm or 4.0 mm partially threaded cannulated screws are inserted over the K-wires to achieve rigid bicortical compression.' Two screws provide more stable fixation and prevent rotation of the graft. Option D is incorrect. The case states, 'A longitudinal split is created in the subscapularis tendon, typically at the junction of the superior two-thirds and inferior one-third, to protect the axillary nerve traversing inferiorly.' Reversing the split location would place the axillary nerve at greater risk. Option E is incorrect. The case states, 'The coracoacromial ligament is sharply released from the lateral aspect of the coracoid, leaving a 1 cm stump for later capsular repair.' This stump is used to repair the native capsule, contributing to the stability.
Question 313
Topic: Shoulder & Hip Sports
A 28-year-old rugby player with recurrent anterior shoulder instability and an 'off-track' Hill-Sachs lesion, but subcritical glenoid bone loss (<13.5%), undergoes an arthroscopic Bankart repair combined with a remplissage procedure. During the diagnostic arthroscopy, the anterior labrum and capsule are mobilized from the anterior glenoid neck. Which of the following steps is most critical to ensure adequate superior shift during the anterior Bankart repair?
Correct Answer & Explanation
. Releasing the tissue inferiorly to the 6 o'clock position.
Explanation
Correct Answer: C. The arthroscopic Bankart repair aims to reattach the avulsed labrum and tighten the anterior capsule to restore stability. Option C is the correct answer. The case states, 'The anterior labrum and capsule are meticulously mobilized from the anterior glenoid neck using an elevator and electrocautery. It is critical to release the tissue inferiorly to the 6 o'clock position to allow for adequate superior shift during repair.' This extensive release is essential to achieve sufficient capsular shift and tension, which is key to preventing recurrent instability. Option A is an important step to create a bleeding bone bed for biological healing, but it does not directly facilitate the superior capsular shift. Option B is generally not the starting point for Bankart repair. Anchors are typically placed from inferiorly (5:30 position) and progressed superiorly to the 3:00 position to restore the anterior bumper and achieve the desired capsular shift. Option D is incorrect. The sutures should pass through the 'capsulolabral complex,' ensuring a healthy bite of the inferior glenohumeral ligament to achieve the superior and lateral capsular shift, as described in the case. Option E is incorrect. The case states, 'Before tying the anterior Bankart anchors, the remplissage is addressed... These sutures are left untied until the anterior repair is complete.' The remplissage sutures are tied after the anterior repair is complete, but the anchors are placed before tying the Bankart anchors.
Question 314
Topic: Shoulder & Hip Sports
A 28-year-old rugby player undergoes an open Latarjet procedure for recurrent anterior shoulder instability with critical glenoid bone loss. Postoperatively, the patient reports numbness and weakness in the biceps and brachialis muscles. Which of the following nerves is most likely injured during the procedure?
Correct Answer & Explanation
. Musculocutaneous nerve
Explanation
Correct Answer: DExplanation:Understanding the neurovascular anatomy around the shoulder is crucial for preventing and identifying complications during Latarjet surgery.Option D (Musculocutaneous nerve)is the correct answer. The case explicitly states under 'Intraoperative Complications' that 'The musculocutaneous nerve enters the conjoint tendon as proximally as 3 to 5 cm distal to the coracoid tip and is at risk during graft harvest and retraction.' The musculocutaneous nerve innervates the biceps brachii and brachialis muscles, and its injury would lead to the described symptoms of numbness and weakness in these muscles.Option A (Axillary nerve)is also at risk during the Latarjet procedure, particularly during inferior capsular release and subscapularis split. Injury to the axillary nerve would primarily affect deltoid function (shoulder abduction) and sensation over the regimental badge area, which is different from the symptoms described.Option B (Radial nerve)injury would typically manifest as wrist drop and weakness in forearm extensors, which is not consistent with the patient's symptoms.Option C (Ulnar nerve)injury would affect intrinsic hand muscles and sensation along the medial forearm and hand, which is not consistent with the patient's symptoms.Option E (Suprascapular nerve)injury would primarily affect the supraspinatus and infraspinatus muscles, leading to weakness in shoulder abduction and external rotation, not biceps/brachialis weakness.
Question 315
Topic: Shoulder & Hip Sports
The biomechanical concept of the 'glenoid track' is central to understanding recurrent anterior shoulder instability with bipolar bone loss. For the 28-year-old rugby player, if his intact inferior glenoid width is measured at 25 mm, what is the calculated width of his glenoid track?
Correct Answer & Explanation
. Approximately 20.75 mm
Explanation
Correct Answer: BExplanation:The glenoid track concept is a critical biomechanical principle for surgical decision-making in shoulder instability.Option B (Approximately 20.75 mm)is the correct answer. The case states, 'The glenoid track is the zone of contact between the humeral head and the glenoid during maximum abduction and external rotation. Its width is calculated as 83 percent of the intact inferior glenoid width.' Therefore, for an intact inferior glenoid width of 25 mm, the glenoid track width would be 0.83 * 25 mm = 20.75 mm.Option A (Approximately 15 mm)is incorrect. This value is not derived from the 83% calculation.Option C (Approximately 25 mm)is incorrect. This represents the full intact glenoid width, not the glenoid track width.Option D (Approximately 13.5 mm)is incorrect. This value is mentioned in the case as a threshold for glenoid bone loss (13.5-15%), not the glenoid track calculation.Option E (Approximately 8.3 mm)is incorrect. This value is not derived from the 83% calculation.
Question 316
Topic: Shoulder & Hip Sports
The 28-year-old rugby player has a history of three anterior glenohumeral dislocations. The case highlights that 'failure to address bipolar bone loss is the leading cause of surgical failure following isolated arthroscopic soft-tissue stabilization.' Which of the following patient characteristics or findings would most strongly indicate a need for an osseous augmentation procedure (e.g., Latarjet) rather than an isolated arthroscopic Bankart repair?
Correct Answer & Explanation
. Critical glenoid bone loss (>15%) and an 'off-track' Hill-Sachs lesion.
Explanation
Correct Answer: DExplanation:The decision between soft-tissue repair and osseous augmentation is primarily driven by the extent of bone loss and the engagement of the Hill-Sachs lesion.Option D (Critical glenoid bone loss (>15%) and an 'off-track' Hill-Sachs lesion)is the correct answer. The case explicitly states under 'Indications and Contraindications' that 'Open Latarjet Procedure' is indicated for 'Critical glenoid bone loss (> 15%)' and 'Off-track Hill-Sachs lesions.' This combination represents the highest risk for recurrence with soft-tissue repair alone and necessitates bone augmentation.Option A (First-time dislocation in a high-demand contact athlete)might warrant an arthroscopic Bankart repair, but without recurrent instability or quantified bone loss, it does not automatically indicate an osseous augmentation procedure. The case lists 'First-time dislocators in high-demand sports' as an indication for 'Arthroscopic Bankart Repair.'Option B (An 'on-track' Hill-Sachs lesion with minimal glenoid bone loss (<13.5%))would typically be managed with an arthroscopic Bankart repair, possibly with a remplissage if the Hill-Sachs is 'off-track' but glenoid bone loss is subcritical. This scenario does not necessitate a Latarjet.Option C (A positive sulcus sign indicating generalized ligamentous laxity)is a risk factor for instability but does not, by itself, mandate osseous augmentation. It might influence the choice of soft-tissue repair technique (e.g., more aggressive capsular plication) but is not the primary driver for bone grafting.Option E (Age over 30 years with a sedentary lifestyle)generally correlates with a lower risk of recurrence compared to younger, active individuals. This demographic might even be considered for non-operative management if it were a first-time dislocation, but it does not indicate a need for osseous augmentation.
Question 317
Topic: Shoulder & Hip Sports
During the postoperative rehabilitation for an arthroscopic Bankart repair, the patient is in the early protective phase (Weeks 0 to 4). Which of the following is the most appropriate instruction regarding external rotation?
Correct Answer & Explanation
. External rotation is strictly limited to 0 degrees.
Explanation
Correct Answer: CExplanation:The early protective phase of rehabilitation is crucial for protecting the surgical repair and preventing re-injury.Option C (External rotation is strictly limited to 0 degrees)is the correct answer. The case states under 'Early Protective Phase' (Weeks 0 to 4) for arthroscopic Bankart repairs, 'external rotation is strictly limited to 0 degrees to protect the anterior capsular repair and the subscapularis split.' This restriction is vital to prevent undue stress on the reattached labrum and tightened capsule, which are most vulnerable in external rotation.Option A (Passive external rotation to 45 degrees is permitted)is incorrect. This level of external rotation is typically introduced later, in the intermediate mobilization phase (Weeks 4 to 8), and even then, it is gradually increased.Option B (Active external rotation to 30 degrees is encouraged)is incorrect. Active motion, especially against resistance, is generally avoided in the early protective phase to prevent stress on the repair.Option D (Active-assisted external rotation to tolerance is allowed)is incorrect for the early protective phase. Any significant external rotation, even active-assisted, can jeopardize the repair.Option E (No restrictions on external rotation, as long as it is pain-free)is incorrect and dangerous. Pain is not the sole indicator of safety in the early postoperative period; strict adherence to protocol is necessary to protect the healing tissues.
Question 318
Topic: Shoulder & Hip Sports
The case describes the Latarjet procedure's 'triple-blocking effect.' Which of the following components contributes to this effect?
Correct Answer & Explanation
. The dynamic sling effect of the conjoint tendon traversing the subscapularis.
Explanation
Correct Answer: CExplanation:The Latarjet procedure provides stability through a combination of mechanisms, known as the triple-blocking effect.Option C (The dynamic sling effect of the conjoint tendon traversing the subscapularis)is the correct answer. The case explicitly states, 'The Latarjet procedure is the workhorse for recurrent instability associated with critical glenoid bone loss (> 15%) or in high-demand contact athletes. It relies on a triple-blocking effect: the osseous augmentation of the glenoid, the dynamic sling effect of the conjoint tendon traversing the subscapularis, and the capsular repair to the coracoacromial ligament stump.' The conjoint tendon (biceps short head and coracobrachialis) acts as a dynamic restraint, particularly with the arm in abduction and external rotation.Option A (The tenodesis of the infraspinatus into the Hill-Sachs lesion)describes the remplissage procedure, which is a different technique used for off-track Hill-Sachs lesions, not a component of the Latarjet's triple-blocking effect.Option B (The restoration of the glenoid track width by the coracoid graft)is partially correct in that the osseous augmentation restores the glenoid's articular arc, but the 'glenoid track' is a concept for Hill-Sachs engagement, not a direct component of the Latarjet's triple-blocking effect as described. The osseous augmentation is one of the three effects, but this option describes it in terms of glenoid track width restoration, which is not the primary description of the triple-blocking effect.Option D (The increased concavity compression provided by the rotator cuff)refers to the general dynamic stability provided by the rotator cuff, which is not specific to the Latarjet procedure's unique blocking mechanisms.Option E (The repair of the posterior capsule to the coracoacromial ligament stump)is incorrect. The repair is of thenative capsuleto thestump of the coracoacromial ligament, and it is theanteriorcapsule, not posterior, that is repaired to the stump. This capsular repair is indeed one of the three blocking effects, but the option incorrectly states 'posterior capsule.'
Question 319
Topic: Shoulder & Hip Sports
During preoperative planning for an anterior shoulder stabilization, the concept of the "glenoid track" is utilized to evaluate bipolar bone loss. A Hill-Sachs lesion is considered "off-track" if its medial margin extends medial to what specific landmark or measurement?
Correct Answer & Explanation
. 83% of the intact glenoid width minus the anterior glenoid bone defect
Explanation
The glenoid track is calculated as 83% of the intact glenoid width. In the presence of anterior glenoid bone loss, this defect width must be subtracted from the 83% value to accurately determine the functional track; lesions extending medial to this are "off-track."
Question 320
Topic: Shoulder & Hip Sports
A 40-year-old male sustains a seizure and is found to have a locked posterior shoulder dislocation. CT imaging reveals a reverse Hill-Sachs lesion (anteromedial humeral head defect) involving 35% of the articular surface. The glenoid is intact. What is the most appropriate surgical management?
Correct Answer & Explanation
. Transfer of the subscapularis tendon and lesser tuberosity into the defect
Explanation
For reverse Hill-Sachs lesions involving 20% to 40% of the articular surface, the modified McLaughlin procedure (transfer of the lesser tuberosity with the subscapularis into the defect) is indicated to prevent the defect from engaging the posterior glenoid rim.
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