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Shoulder & Hip Sports MCQs

Practice Set 26 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 501

Topic: Shoulder & Hip Sports
A 45-year-old recreational tennis player underwent arthroscopic decompression and mini-open repair of a small supraspinatus tendon tear 3 weeks ago after nonsurgical management failed to provide relief. He now has pain, swelling about the wound, erythema, and purulent drainage. The patient is returned to the operating room for irrigation, debridement, and cultures. What is the most common organism causing this infection?
. Staphylococcus epidermidis
. Methicillin-resistant Staphylococcus aureus
. Pseudomonas aeruginosa
. Propionibacterium acnes
. Clostridium tetani

Correct Answer & Explanation

. Propionibacterium acnes

Explanation

In a large series of mini-open rotator cuff repairs, an infection rate of at least 2% was found, with the majority of the infections caused by Propionibacterium acnes. To prevent this complication, the shoulder should be re-prepped before the mini-open incision is made to prevent bacterial contamination from the arthroscopic procedure.

Question 502

Topic: Shoulder & Hip Sports

A 22-year-old ballet dancer undergoes hip arthroscopy for increasing hip pain and popping with activity. She experiences complete resolution of signs and symptoms post-operatively. Her pre- and post-operative magnetic resonance sagittal images shown in Figure A (left, pre-operative; right, post-operative). Which of the following pre-operative physical examination findings may have been positive? Review Topic

. Pain with internal and external rotation of her hip with her hip and knee in an extended position
. Limited motion when moving the hip from flexion-abduction-external rotation to flexion-adduction-internal rotation
. Moving from hip flexion-abduction-external rotation to neutral triggers a popping sensation
. Limitation in active hip range of motion with catching, locking and grinding noted on passive motion
. Pain with a half sit-up and tenderness at the pubic ramus

Correct Answer & Explanation

. Pain with internal and external rotation of her hip with her hip and knee in an extended position

Explanation

This patient has internal snapping hip (coxa saltans), which is caused by the psoas tendon sliding over femoral head, iliopectineal ridge, lesser trochanter exostoses, or iliopsoas bursa.Snapping hip exists in 3 forms: (1) external snapping hip, which is caused by the iliotibial band (ITB) sliding over the greater trochanter, (2) internal snapping hip, and(3) intraarticular snapping hip, which is caused by loose bodies (traumatic, or from synovial chondromatoses) or labral tears. While painless snapping hip requires no treatment, painful snapping hip may be addressed with activity modification, physical therapy, steroid injections. Surgical release (ITB z-plasty or psoas tenotomy) is indicated if nonoperative management is unsuccessful.Ilizaliturri et al. evaluated the results of endoscopic iliopsoas tendon release at the lesser trochanter (10 patients) vs endoscopic transcapsular psoas release from the peripheral compartment (9 patients). There were improvements in WOMAC scores in both groups, and no difference between groups. They conclude that both techniques are equally effective.Marquez Arabia et al. evaluated if the psoas tendon regenerates after tenotomy in 27 patients. At 23 months, they found that tendon regeneration occurred in all patients, toa mean circumference of 84% of the original. One patient had persistent pain, but all had 5/5 hip flexion strength. They hypothesize that the bulk of iliopsoas muscle fibers attaches directly to the proximal femoral shaft without a tendon, preventing retraction and allowing regeneration to occur easily.Figure A shows pre- and post-operative arthroscopic psoas tenotomy magnetic resonance sagittal images. Illustration A shows the psoas tendon (white arrows) prior to transection. Illustration B shows the psoas tendon after transection (green arrows, proximal tendon segment; yellow arrows, distal segment). Illustration C and D are diagrams showing release at the level of the lesser trochanter and hip joint respectively.Incorrect90 degrees, but full external rotation. Answer 2: Decreased internal rotation and a positive impingement test (forcedflexion, adduction, femoroacetabular Answer 4: Theseand internalrotation) are classic findingsfindings maybe found with intra-articularfor cam-type impingement loose bodies.

Question 503

Topic: Shoulder & Hip Sports
A 20-year-old professional baseball pitcher has had a 3-year history of increased aching in his shoulder that is associated with pitching, and he is now seeking a second opinion. Nonsurgical management consisting of rest, anti-inflammatory drugs, ice, heat, and cortisone injections has failed to provide relief. A previous work-up that included radiographs and gadolinium-enhanced MRI arthrography was negative. Results of an arteriogram suggest quadrilateral space syndrome. Assuming that this is the correct diagnosis, what nerve needs to be decompressed?
. Suprascapular
. Infraspinatus branch of the suprascapular
. Long thoracic
. Axillary
. Lateral cord of the brachial plexus

Correct Answer & Explanation

. Axillary

Explanation

Quadrilateral space syndrome is a rare condition resulting from compression of the contents of the quadrilateral space. The contents of the quadrilateral space include the posterior circumflex humeral artery and the axillary nerve.

Question 504

Topic: Shoulder & Hip Sports

A 47-year-old, healthy, active patient presents with a sub-acute, full-thickness supraspinatus tear. His physical examination reveals significant weakness and pain with abduction. There was no glenohumeral instability. Radiographs demonstrate a type 1 acromion. An MRI scan shows a crescent shaped tear with 2-cm of tendinous retraction and no tendinous fatty changes. A subacromial corticosteroid injection 6 weeks ago provided him with 24 hours of pain relief but no improvement in strength. What would be the most appropriate treatment option? Review Topic QID:4501

. Repeat subacromial corticosteriod injection
. Biological augmentation of rotator cuff with porcine small intestine xenograft
. Rotator cuff repair
. Rotator cuff repair plus acromioplasty
. Rotator cuff repair, remplissage procedure, bicep tenodesis and distal clavicle excision

Correct Answer & Explanation

. Rotator cuff repair

Explanation

This patient has an isolated supraspinatus rotator cuff tear with symptomatic weakness. The most appropriate treatment would be isolated rotator cuff repair.The primary purpose of rotator cuff repair is to restore muscle function. Secondary outcomes include reduction of pain and prevention of irreversible cuff changes, specifically muscular atrophy. Non-operative treatment (exercise, therapy and pain medications) are recommended for partial thickness tears. The indication of surgical repair includes, isolated supraspinatus weakness +/- pain that correlates with MRI imaging of a respective full thickness tear. Routine acrominoplasty is not recommended in conjunction with rotator cuff repair, especially with no previous symptoms of impingement.Pedowitz et al. developed clinical practice guidelines for the treatment of rotator cuff pathology. The strongest supporting evidence in current literature was given a grade of 'moderate' with four treatment recommendations. These were,Exercise and non-steroidal anti-inflammatory drugs can be used to manage partial thickness tears,Routine acromioplasty is not required the time of cuff repair,Non-cross-linked, porcine small intestine submucosal xenograft patches should not be used to manage cuff tears, andSurgeons can advise patients that workers' compensation status correlates with a less favorable outcome after rotator cuff surgery.Illustration A shows the different shapes of rotator cuff tears. Incorrect Answers:

Question 505

Topic: Shoulder & Hip Sports

Figures 1 and 2 are the right shoulder MRI scans of a 22-year-old right-handed professional male volleyball player with 4 months of right shoulder pain. The pain began insidiously and is exacerbated by overhead activities and hitting during games. He has maintained a daily program of shoulder stretching and strengthening exercises but has experienced a steady decline in function to the point of not being able to participate in volleyball. Examination reveals some mild atrophy at the posterior shoulder, full forward elevation, mild weakness of external rotation on the right shoulder, negative empty-can testing, positive Oโ€™Brienโ€™s and negative apprehension. Surgical intervention would aim to resolve pathology related to which nerve?

. Lower subscapular nerve
. Suprascapular nerve at the spinoglenoid notch
. Suprascapular nerve at the suprascapular notch
. Axillary nerve

Correct Answer & Explanation

. Lower subscapular nerve

Explanation

This athlete has a symptomatic posterior-superior labral tear, spinoglenoid notch cysts, and subsequent suprascapular nerve compression, as evidenced by the atrophy of the infraspinatus muscle on sagittal T1 MRI. The cyst is located at the spinoglenoid notch and is compressing the suprascapular nerve after it has innervated the supraspinatus but before innervation of the infraspinatus; hence, the atrophy of infraspinatus on examination and imaging. Compression of the suprascapular nerve at the suprascapular notch would lead to weakness and atrophy of both the supraspinatus and infraspinatus. The lower subscapular nerve innervates the teres major, as well as, with the upper subscapular nerve, thesubscapularis. The teres minor is innervated by the axillary nerve.

Question 506

Topic: Shoulder & Hip Sports

A 28-year-old male hockey player presents with anterior groin pain exacerbated by hip flexion and internal rotation. Radiographs reveal a cam-type femoroacetabular impingement (FAI). Which of the following radiographic measurements is most characteristic of this pathology?

. Lateral center-edge angle less than 20 degrees
. Alpha angle greater than 55 degrees on a lateral view
. Tonnis angle greater than 15 degrees
. Crossover sign on the AP pelvis radiograph
. Acetabular index greater than 25 degrees

Correct Answer & Explanation

. Lateral center-edge angle less than 20 degrees

Explanation

Cam-type FAI is caused by an aspherical femoral head-neck junction (loss of native concavity). It is most accurately quantified using the alpha angle, typically measured on a Dunn lateral or frog-leg lateral radiograph (or MRI). An alpha angle >50-55 degrees indicates cam morphology. A crossover sign indicates pincer-type FAI (acetabular retroversion). Lateral center-edge angle <20 and high Tonnis angle denote hip dysplasia.

Question 507

Topic: Shoulder & Hip Sports

A 30-year-old female presents with persistent groin pain exacerbated by hip flexion. An AP pelvis radiograph demonstrates that the center of the femoral head is located medial to the ilioischial line. Which of the following is the most accurate diagnosis?

. Coxa profunda
. Acetabular protrusio
. Cam-type femoroacetabular impingement
. Developmental dysplasia of the hip
. Focal acetabular retroversion

Correct Answer & Explanation

. Coxa profunda

Explanation

Acetabular protrusio is diagnosed when the center of the femoral head (or the medial wall of the acetabulum) crosses medial to the ilioischial line on an AP pelvis radiograph. In coxa profunda, the acetabular fossa touches or crosses the ilioischial line, but the center of the femoral head remains lateral to it.

Question 508

Topic: Shoulder & Hip Sports

In a patient presenting with isolated Pincer-type femoroacetabular impingement (FAI), characterized by focal acetabular overcoverage, what is the classic pattern of chondral damage encountered during hip arthroscopy?

. Broad delamination of the anterosuperior acetabular cartilage from sheer forces.
. Diffuse uniform thinning of the articular cartilage across the entire femoral head.
. A narrow circumferential strip of chondral damage along the acetabular rim with a 'contre-coup' chondral lesion on the posteroinferior acetabulum.
. Central acetabular full-thickness cartilage loss with an intact peripheral rim.
. Isolated ligamentum teres avulsion with corresponding medial head chondromalacia.

Correct Answer & Explanation

. A narrow circumferential strip of chondral damage along the acetabular rim with a 'contre-coup' chondral lesion on the posteroinferior acetabulum.

Explanation

Pincer FAI occurs due to acetabular overcoverage (e.g., retroversion, coxa profunda). The femoral neck linearly impacts the acetabular rim, causing damage to the labrum and a narrow strip of adjacent peripheral cartilage. As the neck levers against the anterior rim, the femoral head is driven backwards, creating a 'contre-coup' chondral lesion on the posteroinferior aspect of the acetabulum or posterior femoral head. In contrast, Cam FAI (nonspherical femoral head) causes sheer stress leading to deep, broad delamination of the anterosuperior acetabular cartilage.

Question 509

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

Correct Answer & Explanation

. Hill-Sachs defect.

Explanation

DISCUSSION: 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 510

Topic: Shoulder & Hip Sports
Which of the following muscles attaches to the coracoid process of the scapula?
. Subscapularis
. Supraspinatus
. Pectoralis minor
. Long head of the biceps brachii
. Serratus anterior

Correct Answer & Explanation

. Pectoralis minor

Explanation

DISCUSSION: The insertion of the pectoralis minor is on the base of the coracoid process. The coracoid helps define the interval between the subscapularis and supraspinatus muscles but neither attaches to it. The coracobrachialis and short head of biceps attach to the tip of the coracoid but are not listed as options. The long head of the biceps attaches to the supraglenoid tubercle. The serratus arises from the vertebral border of the scapula.

Question 511

Topic: Shoulder & Hip Sports

Figures 42a and 42b show the radiographs of a 52-year-old man who sustained a fall from a motorcycle 6 months ago and now reports pain and stiffness in his left shoulder. What is the most reliable treatment to improve function and comfort of the shoulder? Review Topic

. Vigorous physical therapy
. Manipulation under anesthesia
. Arthroscopic capsular release
. Hemiarthroplasty
. Arthroscopic capsular plication

Correct Answer & Explanation

. Hemiarthroplasty

Explanation

Appropriate treatment is based on multiple considerations, which include the chronicity of the dislocation, the amount of humeral head involvement, the medical condition, and functional limitations of the patient. It has been shown that shoulder arthroplasty for locked posterior dislocation provides pain relief and improved motion. Transfer of the lesser tuberosity with its attached subscapularis tendon into the defect is recommended for anteromedial humeral defects that are smaller than approximately 40% of the joint surface. Subscapularis transfer as described by McLaughlin and the modification thereof later described by Hawkins and associates in which the lesser tuberosity is transferred into the defect, have yielded good results if the defect is less than 40% of the humeral head. Prosthetic replacement is preferred for larger defects. If the dislocation is less than 3 weeks old and has less than 25% of humeral head involvement, closed reduction with the patient under general anesthesia should be attempted and the stability assessed by internally rotating the arm. If the arm can be safely internally rotated to the abdomen, then 6 weeks of immobilization in an orthosis that maintains the shoulder in slight extension and external rotation can yield a good result. If the dislocation has been present for more than 3 weeks, closed reduction becomes exceedingly difficult.

Question 512

Topic: Shoulder & Hip Sports
Figures 78a and 78b are the radiographs of a 47-year-old right-hand-dominant woman who has a 3-month history of gradually progressive right shoulder pain. She reports no previous trauma, but does report pain at night and with activity such as weight training. Examination demonstrates active and passive range of motion to be 110 degrees forward elevation, external rotation to 20 degrees, and internal rotation to the sacrum. The next treatment step should include:
. an MRI of the shoulder.
. a physical therapy referral for rotator cuff strengthening and proprioceptive exercise.
. a home stretching program and corticosteroid injection.
. arthroscopic glenohumeral capsular release.

Correct Answer & Explanation

. a home stretching program and corticosteroid injection.

Explanation

This patient has idiopathic adhesive glenohumeral stiffness. Most patients with this condition are women between 40 and 60 years of age with no specific mechanism of onset. Patients typically develop pain, at which point the disease is marked by significant inflammation. This patient is likely in the second stage of the disease, marked by inflammation and early fibrosis of the joint capsule, leading to joint stiffness. The most appropriate treatment step at this stage is an intra-articular glenohumeral corticosteroid injection, most often in conjunction with either a supervised or home-based capsular stretching program. Physical therapy that prioritizes rotator cuff strengthening is more appropriate for patients with isolated subacromial impingement syndrome and may worsen symptoms in patients with stiff shoulders.

Question 513

Topic: Shoulder & Hip Sports

A 22-year-old collegiate rugby player presents with recurrent anterior shoulder instability. A pre-operative CT scan demonstrates a 25% anterior glenoid bone defect. What is the most appropriate surgical treatment to minimize his risk of recurrence?

. Arthroscopic Bankart repair with suture anchors
. Arthroscopic remplissage with Bankart repair
. Open Latarjet procedure
. Iliac crest bone grafting of the humeral head
. Open capsular shift

Correct Answer & Explanation

. Arthroscopic Bankart repair with suture anchors

Explanation

The open Latarjet procedure is the gold standard for patients with recurrent anterior shoulder instability and significant glenoid bone loss (>20-25%), particularly in high-demand contact athletes. Arthroscopic Bankart repair, even with remplissage, has an unacceptably high failure rate in the setting of critical glenoid bone loss.

Question 514

Topic: Shoulder & Hip Sports

During an arthroscopic osteochondroplasty for a cam-type femoroacetabular impingement, the surgeon must avoid extending the resection too far posterolaterally on the femoral neck to prevent avascular necrosis. The retinacular vessels at risk in this region are terminal branches of which artery?

. Superficial circumflex iliac artery
. Lateral femoral circumflex artery
. Medial femoral circumflex artery
. Obturator artery
. Inferior gluteal artery

Correct Answer & Explanation

. Superficial circumflex iliac artery

Explanation

The primary blood supply to the femoral head is provided by the retinacular branches of the medial femoral circumflex artery (MFCA). These vessels course superiorly and posteriorly along the femoral neck and are at risk if an osteochondroplasty for a cam lesion extends excessively posterolaterally.

Question 515

Topic: Shoulder & Hip Sports

A 29-year-old elite volleyball player presents with insidious onset right shoulder weakness. Examination reveals isolated profound atrophy of the infraspinatus with preserved supraspinatus strength and bulk. An MRI is most likely to show nerve compression by a paralabral cyst in which anatomic location?

. Suprascapular notch
. Spinoglenoid notch
. Quadrilateral space
. Triangular interval
. Rotator interval

Correct Answer & Explanation

. Suprascapular notch

Explanation

The suprascapular nerve innervates the supraspinatus muscle before passing through the spinoglenoid notch to innervate the infraspinatus. Entrapment at the spinoglenoid notch (commonly by a cyst associated with a posterior labral tear) results in isolated infraspinatus weakness. Entrapment at the suprascapular notch would affect both muscles.

Question 516

Topic: Shoulder & Hip Sports

A 48-year-old manual laborer presents with persistent shoulder pain. MRI arthrogram reveals an isolated Type II SLAP tear. Nonoperative management has failed. Current literature suggests which of the following surgical interventions provides the most reliable return to work and highest patient satisfaction in this demographic?

. Arthroscopic SLAP repair using one suture anchor
. Arthroscopic SLAP repair using two suture anchors
. Open stabilization of the labrum
. Primary subpectoral biceps tenodesis
. Debridement of the superior labrum without tenodesis

Correct Answer & Explanation

. Arthroscopic SLAP repair using one suture anchor

Explanation

In older patients (typically >35-40 years) and workers' compensation populations, primary biceps tenodesis for isolated Type II SLAP tears has been shown to have lower complication rates, lower reoperation rates, higher satisfaction, and more reliable return to work compared to SLAP repair, which carries a higher risk of postoperative stiffness and persistent pain.

Question 517

Topic: Shoulder & Hip Sports

A 22-year-old competitive rugby player presents with recurrent anterior shoulder instability. He has had four prior dislocations. Imaging reveals a 22% anterior glenoid bone loss and an engaging Hill-Sachs lesion. His Instability Severity Index Score (ISIS) is 7. Which of the following is the most appropriate surgical management?

. Arthroscopic Bankart repair alone
. Arthroscopic Bankart repair with remplissage
. Open Latarjet procedure
. Open Bankart repair with inferior capsular shift
. Superior capsular reconstruction

Correct Answer & Explanation

. Arthroscopic Bankart repair alone

Explanation

In a young, high-demand contact athlete with recurrent anterior instability, significant glenoid bone loss (>20%), and a high ISIS score (>6), soft-tissue stabilization alone carries an unacceptably high failure rate. The Latarjet procedure (coracoid transfer to the anterior glenoid) is the standard of care for restoring stability through the 'triple blocking effect' (increasing articular arc, sling effect of the conjoint tendon, and capsular repair). Remplissage with Bankart is typically reserved for subcritical glenoid bone loss (<15-20%) with off-track engaging Hill-Sachs lesions.

Question 518

Topic: Shoulder & Hip Sports

When utilizing the modified Judet (posterior) approach to the scapula for the fixation of a highly displaced extra-articular scapular body fracture, the primary intermuscular interval is developed between which of the following two muscles?

. Teres minor and teres major
. Supraspinatus and infraspinatus
. Infraspinatus and teres major
. Infraspinatus and teres minor
. Teres major and latissimus dorsi

Correct Answer & Explanation

. Teres minor and teres major

Explanation

The classic Judet approach is an extensile posterior approach reflecting the infraspinatus from medial to lateral. The modified Judet approach minimizes muscle detachment by exploiting the interval between the infraspinatus (suprascapular nerve) and the teres minor (axillary nerve). This exposes the lateral border and body of the scapula for plating.

Question 519

Topic: Shoulder & Hip Sports

On an anteroposterior (AP) radiograph of the pelvis, the 'crossover sign' is indicative of acetabular retroversion. Which of the following correctly describes this radiographic finding?

. The line of the anterior acetabular rim projects medial to the line of the posterior rim in the superior aspect.
. The line of the posterior acetabular rim projects medial to the line of the anterior rim in the superior aspect.
. The ischial spine is visible prominently within the pelvic basin.
. The iliopectineal line intersects the ilioischial line.
. The center of the femoral head lies lateral to the posterior acetabular wall.

Correct Answer & Explanation

. The line of the anterior acetabular rim projects medial to the line of the posterior rim in the superior aspect.

Explanation

The crossover sign is a classic plain radiographic marker of cranial acetabular retroversion, commonly seen in pincer-type femoroacetabular impingement (FAI). It occurs when the projection of the anterior acetabular wall crosses medial to the projection of the posterior acetabular wall on a true AP pelvis radiograph.

Question 520

Topic: Shoulder & Hip Sports

A 45-year-old weightlifter feels a pop in his anterior shoulder. MRI shows an isolated full-thickness subscapularis tendon tear. What structure is most likely to be unstable or subluxated as a result?

. Supraspinatus tendon
. Long head of the biceps tendon
. Short head of the biceps tendon
. Coracohumeral ligament
. Teres minor tendon

Correct Answer & Explanation

. Supraspinatus tendon

Explanation

The subscapularis is crucial for stabilizing the long head of the biceps (LHB) tendon in the bicipital groove. A full-thickness tear often leads to medial subluxation or dislocation of the LHB tendon.

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