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Shoulder & Hip Sports MCQs

Practice Set 25 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 481

Topic: Shoulder & Hip Sports
A 43-year-old bus driver sustains a hyperextension injury to her arm and shoulder 4 months after undergoing an open Bankart repair. Examination reveals increased external rotation, anterior shoulder pain, and internal rotation weakness. Her examination also reveals the findings shown in Figure 44. What is the most likely diagnosis?
. Superior labrum anterior and posterior lesion, type III
. Isolated traumatic dislocation
. Axillary nerve disruption
. Subscapularis rupture
. Internal impingement

Correct Answer & Explanation

. Subscapularis rupture

Explanation

DISCUSSION: An isolated tear of the subscapularis tendon has been noted as early as 1835 by Smith. In Gerber and associates’ 1991 report of 16 men with an average age of 51 years, isolated subscapularis tendon rupture was often caused by a violent hyperextension injury. All patients reported pain anteriorly along with night pain. They also noted pain and weakness of the arm. The lift-off test is performed by having the patient lift the palm of the hand away from the small of the back. The patient must have sufficient internal rotation to allow this test to be performed. A subscapularis rupture is likely if the patient cannot perform the lift-off test. REFERENCES: Hertel R, Ballmer FT, Lombert SM, Gerber C: Lag signs in the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg 1996;5:307-313. Gerber C, Krushell RJ: Isolated rupture of the tendon of the subscapularis muscle: Clinical features in 16 cases. J Bone Joint Surg Br 1991;73:389-394. Greis PE, Kuhn JE, Schultheis J, Hintermeister R, Hawkins R: Validation of the lift-off test and analysis of subscapularis activity during maximal internal rotation. Am J Sports Med 1996;24:589-593. Gerber C, Hersche O, Farron A: Isolated rupture of the subscapularis tendon. J Bone Joint Surg Am 1996;78:1015-1023.

Question 482

Topic: Shoulder & Hip Sports
For which of the following conditions will a rehabilitation program for shoulder instability most likely result in a satisfactory response?
. recurrent traumatic anterior dislocation
. recurrent traumatic posterior dislocation
. traumatic subluxation with no previous dislocation
. traumatic anterior subluxation
. atraumatic involuntary subluxation

Correct Answer & Explanation

. atraumatic involuntary subluxation

Explanation

In a study by Burkhead and Rockwood, shoulder instability was classified with criteria applying to whether a patient had traumatic or atraumatic subluxation of the glenohumeral joint. In this classification Type I is a traumatic subluxation without previous dislocation, Type II is a traumatic subluxation after previous dislocation, Type IIIA is an atraumatic, voluntary subluxation in patients with psychological problems, Type IIIB is an atraumatic, voluntary subluxation in a patient without psychological problems and Type IV is an involuntary subluxation. In their study they found that shoulders that have traumatic instability (type I or type II) had a 15 percent chance of a good or excellent outcome with a rehab program as compared with atraumatic subluxations (type III or type IV) which had an 83 percent good to excellent result. Since answer 5 is the only atraumatic type of subluxation it would statistically stand the best chance for improvement with a rehab program.

Question 483

Topic: Shoulder & Hip Sports
Figure 56 shows an arthroscopic view of the long head of the biceps; it has an incompetent biceps sling and is unstable, and an axial glenohumeral MRI scan reveals that it is dislocated medially out of the intertubercular groove. What structure is also most likely injured?
. Middle glenohumeral ligament
. Supraspinatus
. Infraspinatus
. Subscapularis
. Bankart tear

Correct Answer & Explanation

. Subscapularis

Explanation

It is important to recognize that rotator cuff tears are a common finding in the setting of a dislocated long head of the biceps tendon (LHB) from the intertubercular groove of the shoulder. If a LHB tendon dislocation is found on examination or radiographic work-up, it is imperative to rule out associated rotator cuff pathology, specifically of the subscapularis tendon. The subscapularis tendon is the primary stabilizer of the biceps in the groove.

Question 484

Topic: Shoulder & Hip Sports

One week ago a 25-year-old man slipped on the ice and fell, catching himself on a railing. He sustained an anterior shoulder dislocation that was subsequently reduced without difficulty in the emergency department, and he was discharged in a sling. He is now back for follow-up and reports no pain. Examination reveals no weakness on external rotation strength testing. What is the most appropriate management for this patient? Review Topic

. Arthroscopic Bankart repair
. MRI for possible rotator cuff tear
. Physical therapy
. Sling immobilization for an additional 2 weeks
. Cortisone injection

Correct Answer & Explanation

. Sling immobilization for an additional 2 weeks

Explanation

On the basis of the patient's age, lack of weakness, and the fact that this is a first-time traumatic shoulder dislocation, he is unlikely to have sustained a rotator cuff tear. Immobilization should be continued for 2 more weeks. Scheduling a surgical stabilization procedure at this time is not indicated. Immediate therapy is contraindicated because of the acuity of the injury. A cortisone injection is not indicated in an acute traumatic shoulder dislocation.

Question 485

Topic: Shoulder & Hip Sports

Which of the following best describes the pathologic anatomy of cam impingement of the hip? Review Topic

. Retroversion of the acetabulum
. Posteroinferior labral tears
. Morphologic abnormality of the femoral head
. Femoral anteversion
. Femoral head osteonecrosis

Correct Answer & Explanation

. Morphologic abnormality of the femoral head

Explanation

Cam impingement creates shearing forces that result in an outside-in directed detachment of the labrum in the anterosuperior quadrant. Retroversion of the acetabulum is associated with pincer impingement. The impingement is exhibited with hip flexion. Cam impingement involves a morphologic abnormality of the femoral head. Pincer lesions result from stresses of a normal femoral neck against an abnormal acetabular rim. Cam impingement is not associated with osteonecrosis.

Question 486

Topic: Shoulder & Hip Sports
  • A branch of what nerve is at risk for injury when vigorous superior/medial retraction is applied to the interval between the teres minor and the infraspinatus during a posterior approach to the shoulder?
. radial
. axillary
. suprascapular
. thoracodorsal
. long thoracic

Correct Answer & Explanation

. suprascapular

Explanation

In the posterior approach to the shoulder the suprascapular nerve is located in the superior aspect of operative field coursing through the spinoglenoid notch and on the undersurface of the infra-spinatus muscle. When the interval between the teres minor muscle and the infraspinatus muscle is retracted tension is placed on the infraspinatus muscle as well as the suprascapular nerve, which could damage it. The axillary nerve runs through the operative field, but well below and is not retracted supramedially, so although there is a risk for injury to the axillary nerve it is not from the retraction superior medially. The radial, thoracodorsal and long thoracic nerves all lie anterior to the scapula.

Question 487

Topic: Shoulder & Hip Sports
Figures 39a and 39b show the MRI scans of a 25-year-old man with right shoulder pain. Figure 39c shows the arthroscopic view from a posterior portal in the beach chair position. What is the most likely diagnosis?
. Bankart lesion
. Superior labral tear
. Partial articular surface supraspinatus tear
. Partial bursal surface supraspinatus tear
. Full-thickness supraspinatus tear

Correct Answer & Explanation

. Partial articular surface supraspinatus tear

Explanation

DISCUSSION: The MRI scans show coronal oblique and sagittal oblique views of a partial articular surface supraspinatus tear or tendon avulsion (PASTA lesion). The arthroscopic view is a posterior portal of the glenohumeral joint viewing the articular surface of the supraspinatus. These tears are a common source of shoulder pain and are often amenable to transtendon arthroscopic repair without detachment of the intact bursal surface. REFERENCES: Sanders TG, Miller MD: A systematic approach to magnetic resonance imaging interpretation of sports medicine injuries of the shoulder. Am J Sports Med 2005;33:1088-1105. McConville OR, Iannotti JP: Partial-thickness tears of the rotator cuff: Evaluation and management. J Am Acad Orthop Surg 1999;7:32-43. Burkhart SS: Arthroscopic management of rotator cuff tears, in McGinty JB (ed): Operative Arthroscopy, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 508-546.

Question 488

Topic: Shoulder & Hip Sports
In patients older than age 40 years who sustain a first-time anterior dislocation of the shoulder, prolonged morbidity is most commonly associated with:
. recurrent dislocation.
. posttraumatic arthritis.
. a rotator cuff tear.
. stiffness secondary to immobilization.
. nerve injury.

Correct Answer & Explanation

. a rotator cuff tear.

Explanation

DISCUSSION: In the study done by Pevny and associates, 35% of patients older than age 40 years sustained rotator cuff tears and 8% had axillary nerve palsies. All of the patients with axillary nerve palsy also had rotator cuff tears. Imaging of the rotator cuff is indicated in this age group. The incidence of recurrent instability in patients older than age 40 years is 10% to 15%. REFERENCES: Pevny T, Hunter RE, Freeman JR: Primary traumatic anterior shoulder dislocation in patients 40 years of age and older. Arthroscopy 1998;14:289-294. Sonnabend DH: Treatment of primary anterior shoulder dislocation in patients older than 40 years of age: Conservative versus operative. Clin Orthop 1994;304:74-77. Hawkins RJ, Mohtadi NG: Controversy in anterior shoulder instability. Clin Orthop 1991;272:152-161.

Question 489

Topic: Shoulder & Hip Sports
A woman with a neck and chest tumor has weakness in the biceps and paresthesias in the thumb. Brachioradialis and infraspinatus function are normal. The lesion is affecting which of the following structures?
. C6
. Upper trunk
. Middle trunk
. Posterior cord
. Lateral cord

Correct Answer & Explanation

. Lateral cord

Explanation

The lateral cord terminates as the musculocutaneous nerve and also contributes sensory fibers to the median nerve. Involvement of the C6 root or upper trunk could potentially cause weakness of the infraspinatus and the brachioradialis. The middle trunk and the posterior cord do not contribute motor fibers to the thumb or sensory fibers to the thumb.

Question 490

Topic: Shoulder & Hip Sports

Which of the following postoperative rehabilitation techniques causes minimal rotator cuff muscle activation? Review Topic

. Active forward flexion
. Passive forward flexion
. Active-assisted forward flexion
. Overhead pulley-assisted passive forward flexion
. Isometric strengthening

Correct Answer & Explanation

. Active forward flexion

Explanation

Electromyography (EMG) studies have shown that the rotator cuff is least active with passive range of motion and hence this is allowed early in most postoperative rotator cuff rehabilitation protocols. Active forward flexion, active-assisted motion, and isometric strengthening all cause activation of the rotator cuff muscles (as measured by EMG) and therefore should be introduced later in rehabilitation when the repair can withstand these forces. Whereas some authors have felt that pulley-assisted range of motion exercises are safe, EMG analysis has demonstrated that these exercises do cause activation of the rotator cuff musculature and probably should be avoided early in the rehabilitation protocol.

Question 491

Topic: Shoulder & Hip Sports

A 39-year-old man has had persistent right shoulder pain for the past 6 months. A formal physical therapy program has failed to provide relief, and an injection several months ago provided only short-term relief. Examination reveals a positive Neer and Hawkins test. There is no instability and the neurovascular

. Arthroscopic debridement alone of the partial rotator cuff tear
. Repair of the partial rotator cuff tear and subacromial decompression
. Arthroscopic debridement combined with subacromial decompression
. Arthroscopic subacromial decompression
. Biceps tenotomy

Correct Answer & Explanation

. Arthroscopic debridement alone of the partial rotator cuff tear

Explanation

Although arthroscopic debridement with or without subacromial decompression is a reasonable response, the patient has positive impingement signs. Several recent studies regarding the surgical treatment of partial rotator cuff tears have demonstrated good to excellent results after repair of tears involving more than 50% of the tendon thickness. This was shown specifically for bursal-sided tears and joint-side tears. Biceps tenotomy is not indicated in a young patient.

Question 492

Topic: Shoulder & Hip Sports
A 64-year-old man who underwent total shoulder arthroplasty 4 weeks ago is making satisfactory progress in physical therapy, but his therapist notes limitations in external rotation to neutral. A stretching program is started, and the patient suddenly gains 90 degrees of external rotation but now reports increased pain and weakness. What is the best course of action?
. Early surgical exploration and repair of the torn subscapularis tendon
. Observation and reassurance that the pain will resolve
. A slow progressive resistance program to restore strength
. CT to assess for component malrotation
. Electromyography to evaluate for possible nerve injury

Correct Answer & Explanation

. Early surgical exploration and repair of the torn subscapularis tendon

Explanation

DISCUSSION: Nearly all approaches to shoulder arthroplasty require detachment of the subscapularis tendon from the humerus and subsequent repair. Healing of this tenotomy is one of the limiting factors in postoperative recovery. Failure of the tenotomy repair must be recognized and treated early with repeat repair or pectoralis muscle transfer for optimal results. Failure of the subscapularis is diagnosed clinically as excessive external rotation and weakness, especially in the lift-off or belly press position.

Question 493

Topic: Shoulder & Hip Sports

The patient experiences little improvement with activity modification and more physical therapy. An intra-articular corticosteroid injection provides excellent relief, but relief only lasts for 1 month. The player requests further treatment for his hip and is counseled regarding surgical intervention. Hip arthroscopy is performed. Intrasurgically, a capsulolabral separation is observed with an underlying pincer lesion. No articular cartilage injury is seen. Which treatment is most appropriate considering these findings?

. Debridement of the labral tear plus bony resection of the pincer lesion
. Debridement of the labral tear and no bony resection of the pincer lesion
. Femoral neck osteoplasty plus labral repair using suture anchor
. Resection of the bony pincer lesion plus labral repair using suture anchor

Correct Answer & Explanation

. Debridement of the labral tear plus bony resection of the pincer lesion

Explanation

DISCUSSIONVideo 67 for referenceThis clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among women. Decreased range of motion and pain occur secondary to the abutment of the femoral head against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation, recreates this contact and causes pain, but CAM or pincer etiology remains unknown.The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture, sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology. An ultrasound may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasound is not commonly used to diagnose labral pathology.Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the anterosuperior femoral neck upon the anterior acetabulum may result a “contra-coup” chondral injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this scenario. Without bony resection to prevent further impingement, this patient will continue to experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears should subsequently be repaired after pincer debridement because the labrum has important functions for hip stability and maintenance of the suction seal of the joint.

Question 494

Topic: Shoulder & Hip Sports
During shoulder motion with the elbow controlled in a brace, electromyographic studies of the supraspinatus show significant activity with all range-of-motion testing. Concurrent electromyographic studies of the long head of the biceps will most likely show
. minimal activity.
. moderate activity compared to the supraspinatus.
. significant activity with a supraspinatus tear.
. significant activity with an intact supraspinatus.
. significant activity with both intact and torn rotator cuffs.

Correct Answer & Explanation

. minimal activity.

Explanation

During electromyographic studies, the long head of the biceps has been shown to have little activity throughout a wide range of shoulder motion as long as the elbow is immobilized. The supraspinatus is active throughout the range of shoulder motion. Rotator cuff tears do not influence biceps activity as long as the elbow is controlled.

Question 495

Topic: Shoulder & Hip Sports

Figure 7 is the MR image of a 43-year-old man who has left shoulder pain with a traumatic rotator cuff tear after a fall. An examination reveals active forward elevation at 120 degrees and positive Yergason and lift-off test results. Arthroscopy reveals that the articular surfaces of the glenohumeral joint have a normal appearance without significant degenerative changes. What is the most appropriate treatment at this time?

. Rotator cuff repair and biceps tenodesis
. Rotator cuff repair and loose body removal
. Latissimus dorsi transfer
. Bankart repair

Correct Answer & Explanation

. Rotator cuff repair and biceps tenodesis

Explanation

DISCUSSIONVideo 7 for referenceThe MR image shows medial subluxation of the biceps tendon, which can be confused with an articular loose body. In the clinical scenario of biceps instability/subluxation, the rationale regarding tenodesis is to address the painful dislocation and subluxation of the biceps tendon from the bicipital groove.The MR image does not show a loose body or Bankart lesion. Patients with irreparable rotator cuff tears with a severe external rotation deficit and a deficient teres minor may experience a better functional result with latissimus dorsi transfer.

Question 496

Topic: Shoulder & Hip Sports
  • A right-handed 35-year old man who underwent a Putti-Platt repair for recurrent anterior instability 20 years ago now has increasing shoulder pain and stiffness. Examination of the shoulder reveals internal rotation to the posterior superior iliac spine and external rotation to 10 degrees with the shoulder adducted. The supraspinatus and infraspinatus are moderately atrophied. What is the most likely diagnosis?
. C5 radiculopathy
. Subscapularis rupture
. Glenohumeral arthrosis
. Rotator cuff arthropathy
. Suprascapular nerve compression at the spinoglenoid notch

Correct Answer & Explanation

. C5 radiculopathy

Explanation

Osteoarthrosis of the glenohumeral joint is a potential late complication of the anterior Putti-Platt capsulorrhaphy. Disabling pain in the shoulder began an average of 13.2 after a Putti-Platt repair that had been done for recurrent anterior unidirectional instability. Osteoarthrosis of the glenohumeral joint resulted in substantial limitation of motion. Complications of the Putti-Platt surgery include persistent pain, recurrent subluxation or dislocation, or residual weakness of the shoulder; paresthesias of the musculocutaneous nerve, and infection. This late complication develops when the repair is excessively tight, a 20-25 degree limitation of full external rotation is desired and expected after rehabilitation. The most direct correlation with the severity of osteoarthrosis was the degree of limitation of external rotation.

Question 497

Topic: Shoulder & Hip Sports

A 48-year-old man undergoes arthroscopy to repair a rotator cuff tear. During the arthroscopy, the tear is characterized and found to involve the entire supraspinatus and a majority of the infraspinatus tendons. After mobilization, the posterior rotator cuff can reach the greater tuberosity. However, the supraspinatus tendon cannot reach its insertion point at the greater tuberosity. What is the most appropriate treatment? Review Topic

. Conversion to a latissimus dorsi muscle tendon transfer
. Acromioplasty and coracoacromial ligament release
. Reverse acromioplasty (tuberoplasty)
. Reverse total shoulder arthroplasty
. Partial repair of the rotator cuff

Correct Answer & Explanation

. Conversion to a latissimus dorsi muscle tendon transfer

Explanation

If a complete rotator cuff repair is not possible, a partial rotator cuff repair should still be considered and is the appropriate treatment for this patient. In patients with an irreparable massive rotator cuff tear, acromioplasty with coracoacromial ligamentrelease, reverse acromioplasty, and tenotomy of the biceps tendon may improve shoulder pain. If these procedures fail, then a muscle transfer procedure can also be considered in select patients. If, however, a portion of the rotator cuff can be repaired, even partial repair can balance the coronal and axial forces about the shoulder to restore the kinematics of the joint. Reverse total shoulder arthroplasty is not appropriate for this relatively young patient.

Question 498

Topic: Shoulder & Hip Sports

Figure 1 is the MRI scan of a 19-year-old man who has an acute anterior shoulder dislocation. The bony fragment occupies 10% of the glenoid articular surface. What is the most appropriate treatment? Review Topic

. Open structural iliac crest graft
. Open reduction and internal fixation
. Arthroscopic coracoid transfer
. Arthroscopic repair incorporating the bone lesion

Correct Answer & Explanation

. Open structural iliac crest graft

Explanation

The MRI scan shows a bony Bankart lesion involving less than 20% of the glenoid joint surface. A recent series reported high success rates after arthroscopic treatment when the defect is incorporated into the repair. Anterior bony deficiencies occupying more than 25% to 30% of the glenoid joint surface treated with soft-tissue repair only are associated with high recurrence rates. In these patients, an open or arthroscopic coracoid transfer or structural iliac crest graft should be considered. Open reduction and internal fixation has been reported for treatment of large acute glenoid rim fractures but is not recommended for recurrent anterior shoulder instability in the setting of a 10% glenoid rim fracture.

Question 499

Topic: Shoulder & Hip Sports
A 17-year-old high school football player sustains a traumatic anterior shoulder dislocation, resulting in a small bony Bankart lesion and small Hill-Sachs lesion. The patient undergoes an arthroscopic Bankart repair with incorporation of the bone fragment and returns to play football the following year. He has a recurrent dislocation at football practice but decides to finish the football season before considering additional treatment. He sustains nine additional dislocations, with the last dislocation occurring while sleeping. What diagnostic test is most appropriate when planning revision surgery?
. CT scan with 3D reconstructions
. Ultrasonography
. MRI scan
. Fluoroscopically-guided arthrogram

Correct Answer & Explanation

. CT scan with 3D reconstructions

Explanation

A failed bony Bankart repair with multiple dislocations can further erode the anteroinferior glenoid, changing the sagittal morphology of the glenoid into an “inverted pear.” Quantitative bone loss is best evaluated by CT scan with 3D reconstructions and subtraction of the humeral head. MRI and ultrasonography can assist in evaluating soft-tissue injury, but they are not as helpful in determining bone loss compared with a CT scan. An arthrogram alone is not sufficient to evaluate bone loss. Bone loss >30% necessitates glenoid augmentation with either a Latarjet procedure or iliac crest bone grafting.

Question 500

Topic: Shoulder & Hip Sports
The CT and MRI scans of a patient with shoulder instability are shown. Contrasting these two imaging techniques for decision making in shoulder instability would suggest
. Both CT and MRI have equivalent cost for the patient.
. Both CT and MRI have equivalent safety for the patient.
. Associated soft-tissue damage can be more reliably shown on CT scans.
. Two-dimensional CT scan is generally accepted as a superior imaging modality for evaluating bone loss in shoulder instability than two-dimensional MRI scan.

Correct Answer & Explanation

. Two-dimensional CT scan is generally accepted as a superior imaging modality for evaluating bone loss in shoulder instability than two-dimensional MRI scan.

Explanation

Two-dimensional CT scan is generally accepted as a superior imaging modality for evaluating bone loss in shoulder instability than two-dimensional MRI scan. This advantage is offset by the relatively high radiation dose. Although CT in most situations is less costly, MRI can provide more data regarding associated soft-tissue damage that can be associated with recurrent instability. It should be noted that three-dimensional MRI has recently been shown as equivalent to three-dimensional CT in its ability to identify glenoid bone loss.

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