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Shoulder & Hip Sports MCQs

Practice Set 24 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 461

Topic: Shoulder & Hip Sports

A 55-year-old man who works as a carpenter reports chronic right anterior shoulder pain and weakness. Examination reveals 90 degrees of external rotation (with the arm at the side) compared to 45 degrees on the left side. His lift-off examination is positive, along with a positive belly press finding. An MRI scan reveals a chronic, retracted atrophied subscapularis tendon. What is the most appropriate management of his shoulder pain and weakness? Review Topic

. Shoulder fusion
. Arthroscopic subscapularis repair
. Intra-articular corticosteroid injection
. Open subscapularis repair
. Pectoralis major transfer

Correct Answer & Explanation

. Shoulder fusion

Explanation

Chronic subscapularis tendon ruptures preclude primary repair. In such instances, subcoracoid pectoralis major tendon transfers may improve function and diminish pain. The subcoracoid position of the transfer allows redirection of the pectoralis major in a direction recreating the vector of the subscapularis tendon. Shoulder fusion is a salvage procedure, and corticosteroid injection may reduce pain but will not improve function.

Question 462

Topic: Shoulder & Hip Sports
Figure 7 shows a sagittal T1-weighted MRI scan. What muscle/tendon is identified by the arrow?
. Infraspinatus
. Teres minor
. Subscapularis
. Long head of triceps
. Latissimus dorsi

Correct Answer & Explanation

. Teres minor

Explanation

The sagittal T1-weighted MRI scan is useful for interpreting the quality of muscle. The arrow is pointing to the teres minor.

Question 463

Topic: Shoulder & Hip Sports
A 36-year-old woman has pain and swelling of the anterior arm after undergoing arthroscopic shoulder surgery 8 months ago. At the time of the procedure, extensive debridement and synovectomy of the anterior aspect of the joint was performed to remove scar tissue that had formed after an open rotator cuff repair. Examination reveals a golf ball-sized swelling just lateral to the coracoid. The area is not warm and shows no other signs of infection. An MRI scan is shown in Figure 1. Management should now consist of
. aspiration of the ganglion cyst.
. repair of the supraspinatus tendon.
. repair of the subscapularis tendon.
. repair of the rotator cuff interval.
. repair of the anterior labrum.

Correct Answer & Explanation

. repair of the rotator cuff interval.

Explanation

Deficiency of the rotator cuff interval may be acquired or congenital. In this patient, extensive debridement of the rotator cuff interval capsule at the time of arthroscopy most likely is the cause of the defect seen on the MRI scan. Surgical closure of the defect is the treatment of choice. During the repair, the shoulder should be placed in 30 degrees of external rotation to avoid overtightening. Care should be taken to include the leading edge of both the supraspinatus and subscapularis tendons in the repair because the rotator cuff interval capsular tissue is likely to be of poor quality.

Question 464

Topic: Shoulder & Hip Sports
A 55-year-old man who works as a carpenter reports chronic right anterior shoulder pain and weakness. Examination reveals 90 degrees of external rotation (with the arm at the side) compared to 45 degrees on the left side. His lift-off examination is positive, along with a positive belly press finding. An MRI scan reveals a chronic, retracted atrophied subscapularis tendon. What is the most appropriate management of his shoulder pain and weakness?
. Shoulder fusion
. Arthroscopic subscapularis repair
. Intra-articular corticosteroid injection
. Open subscapularis repair
. Pectoralis major transfer

Correct Answer & Explanation

. Pectoralis major transfer

Explanation

DISCUSSION: Chronic subscapularis tendon ruptures preclude primary repair. In such instances, subcoracoid pectoralis major tendon transfers may improve function and diminish pain. The subcoracoid position of the transfer allows redirection of the pectoralis major in a direction recreating the vector of the subscapularis tendon. Shoulder fusion is a salvage procedure, and corticosteroid injection may reduce pain but will not improve function.

Question 465

Topic: Shoulder & Hip Sports

A 21-year-old professional ballet dancer reports a painful popping sensation over her right hip joint. Examination reveals that symptoms are reproduced with hip flexion and external rotation. Which of the following studies will best confirm the diagnosis? Review Topic

. Radiographs
. Bone scan
. CT
. Ultrasonography
. MRI

Correct Answer & Explanation

. Radiographs

Explanation

The patient has snapping hip syndrome of the internal type, which is more common in ballet dancers. It is caused by the iliopsoas tendon gliding over the iliopectineal line or the femoral head. The diagnosis usually can be made by the history and physical examination. Snapping is reproduced by hip flexion and extension or flexion with external rotation and abduction. Conventional and dynamic ultrasonography will confirm the snapping structure. Radiographs occasionally show calcifications near the lesser trochanter. MRI can be used to rule out other diagnoses that can simulate snapping hip.

Question 466

Topic: Shoulder & Hip Sports

A 69-year-old woman has just undergone an uncomplicated total shoulder arthroplasty for glenohumeral osteoarthritis. A press-fit humeral stem and a cemented all-polyethylene glenoid component were placed. At this point, what is the postoperative rehabilitation plan? Review Topic

. Maintain sling immobilization for 6 weeks, and then begin a global range-of-motion program.
. Maintain sling immobilization for 3 weeks, and then begin a global range-of-motion program.
. Immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side.
. Immediately begin a passive range-of-motion program for forward elevation only; no external rotation is allowed for 6 weeks.
. Immediately begin active range of motion in forward elevation and external rotation to the side with a progression to full rotator cuff strengthening in 3 weeks.

Correct Answer & Explanation

. Maintain sling immobilization for 6 weeks, and then begin a global range-of-motion program.

Explanation

The patient needs to immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side. Sling immobilization without stretching for either 3 or 6 weeks will result in severe stiffness that will compromise her ultimate range of motion. Since she has a good quality subscapularis tendon, there is no need to avoid beginning external rotation to the side. However, starting a strengthening program at 3 weeks risks tearing the subscapularis tendon repair. Active strengthening should not begin for 6 weeks postoperatively to allow the subscapularis tendon repair time to heal.

Question 467

Topic: Shoulder & Hip Sports
A 68-year-old woman has been progressing slowly after undergoing humeral head replacement for a four-part fracture 3 months ago. She has not regained active elevation, she feels an audible clunk on attempting elevation, and she reports pain and weakness. She used a sling for 2 weeks in the immediate postoperative period. Radiographs are shown in Figure 37a through 37c. Management should consist of
. tuberosity and rotator cuff repair with bone graft.
. revision arthroplasty leaving the prosthesis proud to increase humeral length and muscle tension.
. revision total shoulder arthroplasty to neutralize eccentric glenoid wear.
. revision of the humeral head replacement alone with increased retroversion.
. additional therapy to include internal and external rotation strengthening of the rotator cuff.

Correct Answer & Explanation

. tuberosity and rotator cuff repair with bone graft.

Explanation

DISCUSSION: Immediate repair of the tuberosity and rotator cuff is recommended on identifying the avulsion or nonunion. Revising the humeral component to increase tension and length will overtighten the cuff and increase the chance of tuberosity pull-off. The glenoid is uninvolved and should not be replaced. Attempts to strengthen the rotator cuff will be unsuccessful because the insertions are no longer attached to the humerus when the tuberosities avulse.

Question 468

Topic: Shoulder & Hip Sports

Figures 1 and 2 are the MR arthrogram images of a 20-year-old right-hand dominant collegiate basketball player who sustained an initial shoulder dislocation 1 year ago. In the month prior to presentation, he dislocated his shoulder two more times. Each time it occurred when going up for a rebound and an opponent grabbed the ball from behind him, hyperextending his shoulder. Physical examination demonstrates full range of motion, absence of atrophy, a positive apprehension sign and relocation test, and a positive Kim test. What is the best next step?

. Anterior labral repair
. Anterior labral repair and remplissage
. Posterior labral repair and rotator interval closure
. Anterior and posterior labral repair

Correct Answer & Explanation

. Anterior labral repair

Explanation

The mechanism of injury/dislocation is most consistent with anterior glenohumeral joint instability. The axial cuts of the MR arthrogram reveals an anteroinferior labral tear, as well as a posterior labral tear. A Hill-Sachs lesion is also consistent with anterior glenohumeral joint instability. At the time of examination under anesthesia, this patient exhibited 2+ anterior and 2+ posterior glenohumeral joint instability. Patients with pan-labral tears and 270° tears can be challenging to diagnose, because patients can report anterior or posterior shoulder instability alone. Thephysical examination and advanced imaging in these patients are crucial in directing appropriate treatment.

Question 469

Topic: Shoulder & Hip Sports

Which of the following plain radiographic views of the shoulder best reveals a Hill-Sachs lesion of the humeral head?

. Lateral Y
. Scapular AP
. Neutral rotation AP
. Internal rotation AP
. External rotation AP

Correct Answer & Explanation

. Lateral Y

Explanation

Hill-Sachs lesion is an impression fracture of the posterosuperior aspect of the humeral head, produced by contact with the anteroinferior glenoid when dislocated. Hill-Sachs lesion is demonstrated on plain AP radiograph in internal rotation.

Question 470

Topic: Shoulder & Hip Sports
A 22-year-old professional baseball catcher has posterior shoulder pain and severe external rotation weakness with the arm in adduction. Radiographs are normal. MRI scans are shown in Figures 15a through 15c. Management should consist of
. aspiration and steroid injection.
. rest.
. acromioplasty.
. arthroscopic repair and decompression.
. rehabilitation.

Correct Answer & Explanation

. arthroscopic repair and decompression.

Explanation

The MRI scans reveal a large posterior paralabral cyst associated with a posterior-superior labral tear. The cyst appears as a well-defined, smoothly marginated mass with low signal intensity on T1-weighted MRI scans and with high signal intensity on T2-weighted MRI scans. MRI also reveals changes in the supraspinatus and infraspinatus muscles secondary to denervation, including decreased muscle bulk and fatty infiltration. In this case of a professional baseball player with a space-occupying lesion causing nerve compression with an associated labral tear, the treatment of choice is arthroscopic decompression of the cyst and repair of the tear.

Question 471

Topic: Shoulder & Hip Sports

A 72-year-old man who underwent total shoulder arthroplasty 2 years ago slipped on ice and fell on his shoulder 3 weeks ago. Immediately after falling he was unable to elevate his arm. Motor examination reveals deltoid 5-/5, subscapularis 5-/5, external rotation 4-/5, and supraspinatus 2/5. Radiographs are shown in Figures 8a and 8b. What is the most likely diagnosis? Review Topic

. Anterior shoulder dislocation
. Humeral component loosening
. Glenoid component loosening
. Glenoid component catastrophic fracture
. Rotator cuff tear

Correct Answer & Explanation

. Anterior shoulder dislocation

Explanation

The patient has a traumatic rotator cuff tear. The history of the fall, the weakness on examination, and normal radiographic findings make a traumatic rotator cuff tear the most likely diagnosis. An MRI scan can be obtained to further evaluate the integrity of the rotator cuff. The axillary radiograph shows a reduced, nondislocated total shoulder arthroplasty. His radiographs show a well-seated humeral stem and no signs of loosening. The glenoid is a cemented all-polyethylene component with no evidence of radiolucent lines surrounding the cemented pegs. The polyethylene glenoid component is radiolucent; however, the space between the metallic humeral head and the glenoid bone is the thickness of the polyethylene glenoid component. If the humeral head were directly against the glenoid bone, then catastrophic fracture of the glenoid would be the working diagnosis.

Question 472

Topic: Shoulder & Hip Sports
A 51-year-old woman is seen for evaluation of chronic supraspinatus and infraspinatus tendon tears. Three years ago, in an attempted repair the surgeon was unable to repair the supraspinatus and infraspinatus tendon tears. Currently she has a marked amount of pain, reduced range of motion, and weakness. Examination reveals anterosuperior escape. Radiographs show no signs of arthritic changes. You are considering a latissimus dorsi tendon transfer. During the discussion, you mention that
. she can expect to have good pain relief following surgery.
. active forward elevation and external rotation are reliably obtained postoperatively.
. with her current anterosuperior escape, she is likely to have a poor surgical result.
. postoperatively, significant muscular atrophy in the latissimus dorsi commonly occurs.
. no advancement in glenohumeral arthritic changes should occur following surgery.

Correct Answer & Explanation

. with her current anterosuperior escape, she is likely to have a poor surgical result.

Explanation

Latissimus dorsi tendon transfer is considered a surgical option for treatment in patients with chronic supraspinatus and infraspinatus tendon tears. Preoperative subscapularis function is necessary for good clinical results. Additionally, men with active elevation to shoulder level and active external rotation to 20 degrees have predictably good results. Women with active shoulder elevation limited to below chest level have poor results from this procedure and should not be considered candidates. Postoperatively they lack pain control, active elevation, and active external rotation. Muscular atrophy in the latissimus dorsi does not occur, and glenohumeral arthritic changes frequently develop postoperatively.

Question 473

Topic: Shoulder & Hip Sports
Figures 15a and 15b are intrasurgical photographs from the posterolateral viewing portal that were taken at the beginning and end of a right shoulder arthroscopic procedure performed on a 54-year-old man. This technique demonstrates superior results compared to traditional arthroscopic techniques when evaluating which outcome?
. Time to healing
. Retear rate
. Functional outcome scores
. Postsurgical pain scores

Correct Answer & Explanation

. Retear rate

Explanation

DISCUSSION: The images reveal a medium-sized tear of the rotator cuff. As more clinical studies are published comparing double-row with single-row rotator cuff repair, it has become clear that the retear rate is lower with a double-row construct for small and medium-sized tears. This may be attributable to the stronger time-zero repair construct that double-row repair provides. No study to date has demonstrated a significant difference in clinical outcomes (functional and pain scores at any time) or time to healing between the 2 techniques.

Question 474

Topic: Shoulder & Hip Sports
A 35-year-old woman dislocated her right shoulder in a fall from a step stool several months ago. She now reports several painful recurrences. Examination reveals anterior and inferior apprehension that reproduces her symptoms. An MRI scan is shown in Figure 17. Management should consist of
. open repair of the lateral joint capsule disruption.
. open Bankart-type repair of the labral-glenoid tear.
. arthroscopic repair of the Bankart lesion.
. physical therapy for rotator cuff strengthening.
. immobilization for 6 weeks, followed by rehabilitation.

Correct Answer & Explanation

. open repair of the lateral joint capsule disruption.

Explanation

DISCUSSION: The MRI findings reveal a disruption of the humeral insertion of the glenohumeral ligaments and joint capsule (humeral avulsion of the glenohumeral ligament). This lesion has been reported to account for an 8% rate of recurrent dislocation in a subset of patients who are typically older than those with the more common lesions of the glenoid labrum (Bankart lesion). Open repairs have been reported to be successful in the prevention of recurrent instability. Since there is no Bankart lesion, open or arthroscopic labral repairs are not indicated. Nonsurgical management is possible if the patient does not want to undergo surgery; however, the recurrence rate is very high.

Question 475

Topic: Shoulder & Hip Sports

repair of the rotator cuff

. closed reduction and immobilization
. open reduction and immobilization
. open reduction and early passive motion

Correct Answer & Explanation

. closed reduction and immobilization

Explanation

Humeral arthroplasty is indicated when there is a defect equivalent to more than 45 percent of the articular surface of the humeral head or dislocation that had been present for more than six months. Posterior dislocations is often missed during initial management. Twenty-five of forty-one dislocations were diagnosed in less than six months.( Hawkins RJ,JBJS 87)

Question 476

Topic: Shoulder & Hip Sports
Figures 1 and 2 are the radiographs of a 55-year-old man who has a 3-year history of right shoulder pain. He has maximized nonoperative management and is interested in operative treatment. He had an open Bankart repair 20 years ago and did well until a few years ago. What is most important to know when deciding on the best surgical treatment for this patient?
. Range of motion
. Infraspinatus strength
. Activity level
. Quality of the subscapularis

Correct Answer & Explanation

. Quality of the subscapularis

Explanation

The radiographs show severe osteoarthritis of the shoulder. The best surgical option would be an arthroplasty. The major determining factor for which type of arthroplasty to choose is the integrity of the rotator cuff tendons. Although the radiographs do not reveal any obvious signs of rotator cuff failure, the patient had an open Bankart 20 years ago. The integrity of the subscapularis tendon following a previous open shoulder procedure is crucial in deciding which type of arthroplasty to consider. Range of motion and infraspinatus strength do not affect the decision-making process, assuming the rotator cuff is intact. Activity level can be important when deciding whether to proceed with an arthroplasty, but it is not as important as the rotator cuff integrity when choosing which arthroplasty to use.

Question 477

Topic: Shoulder & Hip Sports

When a patient has recurrent anterior shoulder instability, a bony glenoid reconstructive procedure should be considered in which clinical setting?

. Associated humeral avulsion of the glenohumeral ligament (HAGL) lesion
. Non-engaging Hill-Sachs lesion
. Glenoid bone loss of at least 25%
. Anterior labral periosteal sleeve avulsion (ALPSA)

Correct Answer & Explanation

. Associated humeral avulsion of the glenohumeral ligament (HAGL) lesion

Explanation

HAGL lesions may initially be treated without surgery. Recurrent instability in the setting of a HAGL lesion may be treated with a soft-tissue repair. A non-engaging or non-tracking Hill-Sachs lesion may be treated with an anterior soft-tissue (Bankart) repair. A tracking or engaging lesion may be treated with a bony glenoid procedure or a soft-tissue procedure plus remplissage. An ALPSA lesion may be treated with a soft-tissue procedure unless it is associated with a glenoid bony defect >25%. A glenoid bony defect >25% is associated with substantially higher recurrence than defects <20%, and consideration for bony glenoid reconstruction is advised. Consideration of bone augmentation procedures with less severe glenoid bone loss may be consideredin collision athletes.

Question 478

Topic: Shoulder & Hip Sports
Figure 13 shows the MRI scan of a 29-year-old rock climber who reports increasing shoulder pain and weakness. Based on these findings, atrophy will most likely occur in which of the following muscles?
. Infraspinatus and supraspinatus
. Infraspinatus
. Supraspinatus
. Teres minor
. Deltoid

Correct Answer & Explanation

. Infraspinatus

Explanation

The MRI scan shows a cyst at the spinoglenoid notch. These cysts are often associated with a labral injury, such as a superior labrum anterior and posterior (SLAP) lesion. The suprascapular nerve passes through the suprascapular notch and sends motor branches to the supraspinatus and sensory branches to the capsule. At the spinoglenoid notch, the infraspinatus branch of the suprascapular nerve is compressed by the cyst, leading to isolated infraspinatus atrophy. The teres minor and the deltoid are innervated by the axillary nerve.

Question 479

Topic: Shoulder & Hip Sports
What procedure can eliminate a sulcus sign?
. Rotator interval closure
. SLAP repair
. Bankart repair
. Supraspinatus repair
. Subacromial decompression

Correct Answer & Explanation

. Rotator interval closure

Explanation

A sulcus sign represents inferior subluxation of the shoulder. The elimination of this sign and correction of the inferior subluxation is best achieved through either an open or arthroscopic rotator interval closure. A SLAP repair stabilizes the biceps anchor but does not affect the sulcus sign. A Bankart repair, which corrects anterior-inferior laxity, is not sufficient to eliminate a sulcus sign. Subacromial decompression and supraspinatus repairs have no effect on inferior subluxation.

Question 480

Topic: Shoulder & Hip Sports
Figure 24 shows the radiograph of a 36-year-old volleyball player with right hip pain. What is the cause of the pain?
. Osteonecrosis
. Rheumatoid arthritis
. Developmental dysplasia of the acetabulum
. Femoral neck fracture
. Femoral acetabular impingement

Correct Answer & Explanation

. Femoral acetabular impingement

Explanation

DISCUSSION: Femoral acetabular impingement usually presents in active young adults with the slow onset of groin pain that often starts after a minor trauma. Physical examination reveals limitation of motion with a positive impingement test which consists of forceful internal rotation with flexion and adduction. Femoral acetabular impingement is a mechanism for the development of early osteoarthritis in nondysplastic hips.

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