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Shoulder & Hip Sports MCQs

Practice Set 23 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 441

Topic: Shoulder & Hip Sports

A patient with deficient anteroinferior bone stock undergoes a Latarjet procedure that transfers a portion of the coracoid to the glenoid rim and secures it with two screws. After surgery, the patient reports numbness on the anterolateral forearm. To verify the diagnosis, what muscle should be tested for strength?

. Axillary
. Abductor pollicis brevis
. Supinator
. Triceps
. Biceps

Correct Answer & Explanation

. Axillary

Explanation

DISCUSSION: A Latarjet procedure is similar to a Bristow procedure, but with the Latarjet procedure a larger portion of the coracoid is transferred to the scapular neck at the anteroinferior glenoid.  As in a Bristow procedure, if the fragment is pulled or twisted during the dissection or during fixation, the musculocutaneous nerve can be injured.  With loss of biceps function, elbow flexion and forearm supination will be weaker.REFERENCES: Ho E, Cofield RH, Balm MR, Hattrup SJ, Rowland CM: Neurologic complications of surgery for anterior shoulder instability.  J Shoulder Elbow Surg 1999;8:266-270.Boardman ND 3rd, Cofield RH: Neurologic complications of shoulder surgery.  Clin Orthop 1999;368:44-53.Allain J, Goutallier D, Glorion C: Long-term results of the Latarjet procedure for the treatment of anterior instability of the shoulder. J Bone Joint Surg Am 1998;80:841-852.

Question 442

Topic: Shoulder & Hip Sports

A 35-year-old man reports a 2-year history of right groin pain. The pain is made worse with hip flexion, prolonged sitting, and cycling. A radiograph and MRI scan are shown in Figures 16a and 16b. Nonsurgical management has failed to provide relief. What is the best surgical option?

. Arthroscopic labral debridement
. Reverse periacetabular osteotomy
. Resurfacing hip arthroplasty
. Femoral neck osteochondroplasty and resection of the detached labrum
. Femoral neck osteochondroplasty and reattachment of the labrum

Correct Answer & Explanation

. Arthroscopic labral debridement

Explanation

DISCUSSION: The patient has cam-type femoral acetabular impingement. He still has a well-maintained joint space without significant degenerative changes, and given his age a joint preserving procedure would be the procedure of choice. A reverse periacetabular osteotomy may be considered in a retroverted acetabulum; however, that is not the case here. A femoral neck osteochondroplasty is required to remove the cam of bone and reshape the femoral head- neck junction to improve the femoral head/neck ratio (femoral head offset). Typically, in isolated cam impingement, cartilage damage in the anterior-superior acetabulum precedes labral damage. Labral debridement alone does not address the pathology of impingement. In cases where labral detachment is present, reattachment has been shown to be superior to labral resection.REFERENCES: Espinosa N, Rothenfluh DA, Beck M, et al: Treatment of femoro-acetabular impingement: Preliminary results of labral refixation. J Bone Joint Surg Am 2006;88:925-935.Parvizi J, Leunig M, Ganz R: Femoroacetabular impingement. J Am Acad Orthop Surg 2007;15:561-570. Trousdale RT: Acetabular osteotomy: Indications and results. Clin Orthop Relat Res 2004;429:182-187.

Question 443

Topic: Shoulder & Hip Sports

A 73-year-old man who underwent repair of the left rotator cuff 6 years ago reports good pain relief but notes residual weakness of the left shoulder, especially with overhead tasks. He denies having pain at night and has minimal discomfort with activities of daily living but is dissatisfied with his shoulder strength. Radiographs show an acromiohumeral interval of 2 mm. Appropriate management should consist of

. an exercise program.
. revision rotator cuff repair using local tissue transposition.
. revision rotator cuff repair using allograft.
. latissimus dorsi transfer.
. combined latissimus dorsi and teres major transfer.

Correct Answer & Explanation

. an exercise program.

Explanation

DISCUSSION: An exercise program to strengthen the deltoid and remaining rotator cuff will most likely offer the best results.  Revision rotator cuff surgery yields better results in decreasing pain than improving strength and function, and this patient has only minimal pain.  Tendon transfers, involving the use of the latissimus dorsi or teres major, have been used when the rotator cuff is deemed irreparable but are not indicated in elderly patients with minimal symptoms.REFERENCES: Bigliani LU, Cordasco FA, McIlveen SJ, Musso ES: Operative treatment of failed repairs of the rotator cuff.  J Bone Joint Surg Am 1992;74:1505-1515.DeOrio JK, Cofield RH: Results of a second attempt at surgical repair of a failed initial rotator-cuff repair.  J Bone Joint Surg Am 1984;66:563-567.Gerber C, Vinh TS, Hertel R, Hess CW: Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff: A preliminary report.  Clin Orthop 1988;232:51-61.

Question 444

Topic: Shoulder & Hip Sports

A 36-year-old woman reports vague right shoulder pain. She denies any previous shoulder problems or any recent trauma. MRI scans are shown in Figures 81a and 81b. Weakness of which of the following is the most likely finding in her physical examination? Review Topic

. Shoulder abduction and internal rotation
. Shoulder external rotation and scapula protraction
. Shoulder external rotation with the arm at the side
. Shoulder internal rotation with the arm at the side
. Scapula protraction

Correct Answer & Explanation

. Shoulder abduction and internal rotation

Explanation

The MRI scans show a cyst formation within the suprascapular notch that can compress the suprascapular nerve. The suprascapular nerve innervates both the supraspinatus and the infraspinatus muscles. Therefore, patients with compression of this nerve may demonstrate weakness of shoulder abduction and external rotation with the arm at the side. If the nerve is compressed after its innervation of the supraspinatus muscle, however, patients will demonstrate weakness of shoulder external rotation only. Suprascapular nerve does not innervate muscles that control scapula motion or shoulder internal rotation.

Question 445

Topic: Shoulder & Hip Sports

Figure 28 shows an arthroscopic view of a right shoulder in the lateral position through a posterior portal. What is the area between structure B (biceps) and SS (subscapularis tendon)? Review Topic

. Inferior glenohumeral ligament
. Superior glenohumeral ligament
. Rotator cuff interval
. Subscapularis recess
. Interior recess

Correct Answer & Explanation

. Inferior glenohumeral ligament

Explanation

The rotator cuff interval is located between the supraspinatus and subscapularis and the biceps tendon is deep to the interval. It is a triangular area where the base is the coracoid process and the apex is the transverse humeral ligament at the biceps sulcus. Closure or tightening of this area is often helpful in patients with shoulder instability. Conversely, this area is often contracted in patients with adhesive capsulitis and may need to be released.

Question 446

Topic: Shoulder & Hip Sports

A baseball player reports a dull pain in the posterior aspect of his throwing arm. Examination reveals decreased internal rotation and prominence of the inferomedial corner of the scapula. An MRI scan suggests a partial-thickness tear of the posterior supraspinatus tendon. Successful treatment would most likely include which of the following? Review Topic

. Anti-inflammatory medication, posterior capsular stretching, and rotator cuff strengthening
. SLAP repair
. Debridement of the partial-thickness rotator cuff tear
. Rotator cuff repair
. Imbrication of the labrum and anterior capsule

Correct Answer & Explanation

. Anti-inflammatory medication, posterior capsular stretching, and rotator cuff strengthening

Explanation

Internal impingement is related to an internal rotation contracture (GIRD-glenohumeral internal rotation deficit) and an increase in external rotation caused by repetitive overhead throwing. Most patients can be successfully treated with rehabilitation that focuses on internal rotation stretches along with anti-inflammatory medication and strengthening as symptoms improve. SLAP repair and rotator cuff debridement may be considered in refractory cases. Rotator cuff repair is not typicallyrequired, and capsulolabral imbrication is more consistent with the surgical treatment for multidirectional instability.

Question 447

Topic: Shoulder & Hip Sports

A 62-year-old man with a long history of right shoulder pain and weakness is scheduled to undergo hemiarthroplasty. Based on the radiographs shown in Figures 6a through 6c, what preoperative factor will most affect postoperative functional outcome?

. Humeral head erosion
. Glenoid erosion
. Rotator cuff integrity
. Status of the coracoacromial ligament
. Acromioclavicular arthritis

Correct Answer & Explanation

. Humeral head erosion

Explanation

DISCUSSION: The radiographs reveal osteoarthritis and proximal humeral head migration.  Integrity of the rotator cuff must be questioned based on these radiographic changes.  The status of the rotator cuff is the most influential factor affecting postoperative function in shoulder hemiarthroplasty.  The coracoacromial ligament provides a barrier to humeral head proximal migration in the face of a rotator cuff tear.  The radiographs do not indicate significant humeral head or glenoid erosion.  Acromioclavicular arthritis is often asymptomatic.REFERENCES: Iannotti JP, Norris TR: Influence of preoperative factors on outcome of shoulder arthroplasty for glenohumeral osteoarthritis. J Bone Joint Surg Am 2003;85:251-258.Hettrich CM, Weldon E III, Boorman RS, et al: Preoperative factors associated with improvements in shoulder function after humeral hemiarthroplasty.  J Bone Joint Surg Am 2004;86:1446-1451.

Question 448

Topic: Shoulder & Hip Sports

Figures 57a and 57b are the MRI scans of a 61-year-old man who is unable to elevate his dominant arm following a golf injury 24 hours ago. He has moderate pain during attempted arm elevation. Examination reveals significant spinati atrophy and he is only able to elevate his arm fully overhead while supine. The neurologic examination is normal. What is the next most appropriate step in management? Review Topic

. Lidocaine injection test
. Supraspinatus strengthening
. Reverse shoulder arthroplasty
. Conventional total shoulder arthroplasty
. Arthroscopic rotator cuff repair/subacromial decompression

Correct Answer & Explanation

. Lidocaine injection test

Explanation

The patient unknowingly has a chronic massive rotator cuff tear. Because of excellent compensation, he remained functional and was without symptoms. This is evidenced by the significant muscle atrophy. Following even trivial injury, the compensation process of arm elevation fails and the patient suddenly loses the ability to elevate the arm. At this time in management, it is critical to recognize that the rotator cuff had already been torn and that pain now prevents the patient from actively using the arm. To better ascertain a prognosis of return of function, injecting a local anesthetic (lidocaine) into the joint is important. If, with an anesthetized joint, the patient can now elevate the arm, a supine strengthening program will likely return the patient to his pre-injury state. If there is no improvement in the ability to elevate the arm after the injection, surgical considerations may become relevant. There is no role for arthroscopic repair in this chronic, massive rotator cuff tear and decompression would likely lead to superior escape. A reverse shoulder arthroplasty would be contraindicated in a very active 61-year-old patient who 2 days ago was functioning normally. Based on the MRI scan, there is no supraspinatus muscle remaining to strengthen. Total shoulder arthroplasty is contraindicated in patients with a deficient rotator cuff mechanism.

Question 449

Topic: Shoulder & Hip Sports

Figures 1 and 2 are the MR arthrogram images of a 16-year-old, right-hand-dominant baseball player who injured his left shoulder 4 weeks ago during a game. He now has pain, weakness, and the inability to swing a bat and can no longer do push-ups. He denies prior injury to his left shoulder. Radiographs are unremarkable. The patient fails an extensive course of physical therapy and is unable to return to baseball. He and his orthopaedic surgeon elect to proceed with surgery. During a repeat evaluation, he has negative sulcus and Beighton sign findings, and radiographs show 5° of glenoid retroversion. What is the most appropriate surgical plan?

. Arthroscopic infraspinatus tenodesis
. Arthroscopic posterior labral repair
. Arthroscopic capsular shift and rotator interval closure
. Posterior glenoid opening-wedge osteotomy

Correct Answer & Explanation

. Arthroscopic infraspinatus tenodesis

Explanation

Posterior shoulder instability is a rare form of instability that often presents with pain rather than feelings of instability. It often occurs in young athletes during activities that put the shoulder in an “at-risk position” (flexion, adduction, internal rotation). Repetitive microtrauma can lead to posterior shoulder instability such as seen in football linemen. Swinging a bat or golf club places the lead arm in a flexed, adducted, and internally rotated position, which can lead to posterior translation of the humeral head that is forcibly reduced in follow-through, as seen in this patient. The glenohumeral joint relies on static and dynamic stabilizers. Static stabilizers help prevent instability at the end ranges of motion when the ligaments are taut. Dynamic stabilizers work to prevent subluxation at midranges of motion, at which the ligaments are lax. The rotator cuff is integral as a dynamic stabilizer of the shoulder. It works through a process called concavity compression. The four muscles of the rotator cuff compress the humeral head into the concavity of the glenoid-labrum. This prevents the humeral head from subluxing during the midranges of motion. Of the four rotator cuff muscles, the subscapularis is most important at preventing posterior subluxation. This patient has posterior instability, and various surgical techniques may be indicated depending on findings. Arthroscopic labral repair is indicated for anterior instability. Arthroscopic posterior labral repair is indicated for this patient because he has a posterior labral tear and posterior instability. If a patient has ligamentous laxity (not seen in this scenario because sulcus and Beighton sign findings would be negative), a posterior capsular shift with rotator interval closure is indicated. If a patient has excessive glenoid retroversion (not seen in this scenario with 5 degrees of retroversion), a posterior opening-wedge osteotomy is appropriate. The most common complication seen after arthroscopic posterior labral repair is stiffness, followed by recurrent instabilityand         degenerative         joint         disease.

Question 450

Topic: Shoulder & Hip Sports
A 24-year-old man has bilateral hip pain. An examination and imaging studies (plain radiographs and MR imaging) confirm evidence of femoroacetabular impingement (FAI) with a CAM deformity in both hips. The patient mentions that he has a 19-year-old brother who has occasional hip pain. With respect to his brother’s pain, how should you counsel the patient?
. His younger brother’s hip pain is almost certainly attributable to some other cause
. His younger brother’s hip pain likely represents established osteoarthritis of the hip
. His younger brother’s hip pain may be related to FAI
. There is no known genetic influence in the etiology of FAI

Correct Answer & Explanation

. His younger brother’s hip pain may be related to FAI

Explanation

DISCUSSION: Evidence suggests that FAI is more common in siblings of patients with FAI, particularly those with a CAM deformity. It is unlikely this patient has well-established osteoarthritis, even in the presence of FAI.

Question 451

Topic: Shoulder & Hip Sports
A 25-year-old man injures his shoulder while skiing. Examination reveals increased passive external rotation, pain in the cocked position, and a positive lift-off test. What is the most likely diagnosis?
. Ruptured biceps tendon
. Subscapularis tear
. Anterior subluxation
. Internal impingement syndrome
. Locked posterior dislocation

Correct Answer & Explanation

. Subscapularis tear

Explanation

A positive lift-off test and increased passive external rotation are diagnostic of a subscapularis tear or detachment. Although a similar injury could produce anterior instability, this will test the integrity of the subscapularis. A locked dislocation has limited passive movement. A ruptured biceps tendon will most likely produce ecchymosis and findings similar to supraspinatus trauma. Internal impingement is not associated with subscapularis weakness.

Question 452

Topic: Shoulder & Hip Sports
A football lineman who sustained a traumatic injury while blocking during a game now reports that his shoulder is slipping while pass blocking. Examination reveals no apprehension in abduction and external rotation; however, he reports pain with posterior translation of the shoulder. He has full strength in external rotation, internal rotation, and supraspinatus testing. What is the pathology most likely responsible for his symptoms?
. Anterior glenoid rim fracture tear
. Anterior inferior labral tear
. Posterior labral tear
. Total capsular laxity
. Osteochondral defect of the humeral head

Correct Answer & Explanation

. Posterior labral tear

Explanation

Traumatic posterior instability is a common finding in football players. A traumatic blow to the outstretched arm results in posterior glenohumeral forces. Labral detachment at the glenoid rim is common. Patients report slipping or pain with posteriorly directed pressure. Posterior repair has been shown to be successful in the treatment of traumatic instability.

Question 453

Topic: Shoulder & Hip Sports

Figures 76a and 76b are the sagittal T1-weighted MRI scans of an active 27-year-old man who has had left dominant extremity shoulder pain and weakness for the past 5 months. He denies any history of a precipitating event but recalls that the pain began around the time he started lifting weights after a year off from lifting. Examination reveals full range of active and passive motion, negative Hawkins and Neer impingement signs, 5/5 abduction strength, 5/5 external rotation strength with arm adducted at his side, and a negative belly press, Gerber lift-off, and O'Brien's test. He does have weakness with resisted external rotation with the arm abducted to 90 degrees. Radiographs are unremarkable. An MRI arthrogram shows no rotator cuff tear or labral tears. What is the most likely diagnosis? Review Topic

. Scapular dyskenisia
. Quadrilateral space syndrome
. Subacromial impingement syndrome
. Suprascapular nerve compression by a spinoglenoid notch
. Suprascapular nerve compression at the suprascapular notch

Correct Answer & Explanation

. Scapular dyskenisia

Explanation

Examination reveals weakness of the teres minor muscle, and the MRI scan shows moderate isolated atrophy of the teres minor muscle belly. This is consistent with quadrilateral space syndrome, which is compression of the axillary nerve and posterior circumflex humeral artery in the quadrilateral space (bounded by the teres minor, teres major, long head of triceps and the humerus). This syndrome has been related to compression of the neurovascular structures by muscle hypertrophy consistent with the patient's history of lifting weights near the onset of symptoms. The next step in confirming the diagnosis is a subclavian arteriogram with the arm in adduction as well as in abduction and external rotation. Suprascapular nerve compression would be manifested by atrophy and weakness of both the supraspinatus and infraspinatus (if occurring at the suprascapular notch) or just infraspinatus (if occurring at the spinoglenoid notch). The patient does not demonstrate signs or symptoms of either impingement syndrome or scapular dyskenisia.

Question 454

Topic: Shoulder & Hip Sports

Figure 4a shows the radiograph of a 20-year-old man who has an injury to the right shoulder. Figure 4b shows an arthroscopic view (posterior portal). The arrow points to a Review Topic

. rotator cuff tear.
. bare area.
. Hill-Sachs defect.
. Bankart tear.
. glenoid fracture.

Correct Answer & Explanation

. rotator cuff tear.

Explanation

The radiograph shows an anterior dislocation of the shoulder. A frequently encountered sequela of this is a compression fracture of the posterolateral humeral head, commonly referred to as a Hill-Sachs defect. The arthroscopic view of the glenohumeral joint visualizes the posterior aspect of the humeral head. In the image, the area devoid of cartilage to the right is the bare area. The indentation seen to the left is a Hill-Sachs defect.

Question 455

Topic: Shoulder & Hip Sports

Figures 26a through 26c show the MRI scans of a 47-year-old man who underwent arthroscopic shoulder surgery 6 months ago and continues to have pain despite a prolonged course of rehabilitation. Management should now consist of Review Topic

. rotator cuff repair.
. revision acromioplasty.
. fragment excision.
. open reduction and internal fixation.
. continued rehabilitation.

Correct Answer & Explanation

. fragment excision.

Explanation

The MRI scans show an os acromiale of the mesoacromion type. This represents an unfused acromial apophysis. Pain is thought to be caused by either motion at the site or downward displacement of the anterior aspect of the acromion onto the rotator cuff, causing impingement. Most patients can be treated nonsurgically as they are usually asymptomatic. In those patients with persistent symptoms of pain and tenderness over the acromion, surgery consisting of rigid internal fixation and bone grafting has yielded satisfactory results. Excision may be a viable treatment option for the preacromion type.

Question 456

Topic: Shoulder & Hip Sports

What complication is most likely to occur following proximal humeral fixation with a locked plate-and-screw construct?

. Screw penetration
. Rotator cuff injury
. Axillary nerve damage
. Fracture of the humeral shaft
. Impingement

Correct Answer & Explanation

. Screw penetration

Explanation

Proximal humeral locking plates have been associated with screw penetration (incidence 23%). The rotator cuff injury is not due to the plate or its application and is associated with dislocations in the elderly. Axillary nerve damage, while possible, has a low reported incidence from open reduction and internal fixation of the proximal humerus with locking constructs. Impingement and fracture of the humeral shaft are also unlikely. More likely but not offered as a choice is the problem of varusreduction which can result in failure. However, penetration of the screws remains the most commonly reported complication.

Question 457

Topic: Shoulder & Hip Sports

A 67-year-old woman is seen in the emergency department after falling at home. Radiographs before and after treatment are shown in Figures 49a and

. Axillary nerve palsy
. Spinal accessory nerve palsy
. Deltoid avulsion
. Rotator cuff tear
. Unreduced posterior glenohumeral dislocation

Correct Answer & Explanation

. Rotator cuff tear

Explanation

Patients older than age 40 years at the time of initial anterior dislocation have low rates of redislocation; however, 15% of these patients experience a rotator cuff tear. Moreover, there is a dramatic increase (up to 40%) in the incidence of rotator cuff tears in patients older than age 60 years. Axillary nerve injury may occur but is less common than rotator cuff tear.

Question 458

Topic: Shoulder & Hip Sports

A 17-year-old quarterback reports shoulder pain localized over the anterior aspect of the shoulder that occurs during the follow through phase of throwing. The pain worsens toward the end of the game, but becomes asymptomatic the next day. He denies any pain during the cocking phase of throwing or during normal daily activities. Examination reveals a negative relocation test and a negative posterior load and shift test. Motion of the shoulder is normal. An MRI arthrogram is shown in Figure 75. Based on the history, examination, and MRI findings, what initial treatment should be recommended? Review Topic

. Labrum repair
. Capsular release
. Labrum debridement
. Physical therapy emphasizing a throwing program
. Physical therapy emphasizing an internal rotation stretching program

Correct Answer & Explanation

. Physical therapy emphasizing a throwing program

Explanation

The MRI scan shows a small amount of contrast between the posterior labrum and the glenoid, suggesting a posterior labral tear. The patient's symptoms are more consistent, however, with rotator cuff deconditioning because of the timing of his pain during the throwing motion and increased severity at the end of the game. Treatment should focus on reconditioning of the rotator cuff and scapular stabilizers, combined with a return to throw program. Posterior labral tears are often found on MRI scans of asymptomatic throwers, and therefore, should not be considered the primary cause of a patient's symptoms unless it is supported by the history and physical examination. Internal rotation contractures can cause a similar pain pattern, but this patient has full and equal range of motion.

Question 459

Topic: Shoulder & Hip Sports
  • A right-handed, 53 year old man reports pain in the left shoulder following a fall on an abducted externally rotated shoulder 3 months ago. Examination reveals pain on elevation and tenderness localized to the anterior aspect of the shoulder. Results of the lift-off test are inconclusive due to limited internal rotation. Figure 2 shows the T1-weighted axial image from an MRI-arthrogram. Treatment should include
. Labral repair
. acromioplasty
. excision of the coracoid process
. an arthroscopic Bankart procedure
. subscapularis repair

Correct Answer & Explanation

. subscapularis repair

Explanation

Subscapularis repair-Traumatic rupture of the tendon of the subscapularis muscle is caused by forceful hyperextension or external rotation of the adducted arm. A simple clinical maneuver called the "lift-off test", reliably diagnosed or excluded clinically relevant rupture of the subscapularis tendon.

Question 460

Topic: Shoulder & Hip Sports
A 54-year-old man has left shoulder pain and weakness after falling while skiing 4 months ago. Examination reveals full range of motion passively, but he has a positive abdominal compression test and weakness with the lift-off test. External rotation strength with the arm at the side and strength with the arm abducted and internally rotated are normal. MRI scans are shown in Figures 1a and 1b. Treatment should consist of:
. Arthroscopy and labral repair.
. Arthroscopy and supraspinatus repair.
. Arthroscopy and subscapularis repair.
. Arthroscopy and supraspinatus and infraspinatus repair.
. Open repair of the pectoralis major.

Correct Answer & Explanation

. Arthroscopy and subscapularis repair.

Explanation

DISCUSSION: The examination findings are consistent with subscapularis muscle weakness but normal supraspinatus and infraspinatus strength. The lift-off test and abdominal compression test are specific for subscapularis function. The MRI scan reveals a chronic avulsion and retraction of the subscapularis. The transverse image reveals a normal infraspinatus muscle, and the sagittal image reveals an atrophic subscapularis. Surgical repair of the isolated subscapularis tendon is indicated. REFERENCES: Iannotti JP, Williams GR: Disorders of the Shoulder: Diagnosis and Management, ed 1. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 31-56. Gerber C, Hersche O, Farron A: Isolated rupture of the subscapularis tendon: Results of operative treatment. J Bone Joint Surg Am 1996;78:1015-1023.

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