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Shoulder & Hip Sports MCQs

Practice Set 28 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 541

Topic: Shoulder & Hip Sports

Figure 1 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion with internal rotation and adduction reproduces his groin pain.What is the most likely cause of this patient's pain?

. Femoroacetabular impingement (FAI)
. Osteoarthritis of the sacroiliac joint
. Intra-articular loose body
. Trochanteric bursitis

Correct Answer & Explanation

. Femoroacetabular impingement (FAI)

Explanation

This 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. Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasonography 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 in 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 hasimportant functions for hip stability and maintenance of the suction seal of the joint.

Question 542

Topic: Shoulder & Hip Sports

A 23-year-old man reports pain on the superior aspect of his right shoulder with repetitive overhead activities and when lying on his right side. Figure 29 shows an axial MRI scan. What is the most likely diagnosis based on the MRI findings? Review Topic

. Osteoarthritis of the acromioclavicular joint
. Acromioclavicular joint separation
. Os acromiale
. Partial-thickness rotator cuff tear
. Superior labral tear

Correct Answer & Explanation

. Osteoarthritis of the acromioclavicular joint

Explanation

Os acromiale represents a failure of fusion of the anterior acromial apophysis and has been reported in approximately 8% of the population. Patients with a symptomatic os acromiale often report impingement-type symptoms with pain over the superior acromion, especially with overhead activities or sleeping. When nonsurgical management is unsuccessful, surgical options include excision, open reduction and internal fixation, and arthroscopic decompression.

Question 543

Topic: Shoulder & Hip Sports
  • A 16-year-old girl who swims on her high school team reports pain in the shoulder after swimming. History reveals a glenohumeral dislocation at age 14 years while doing the backstroke. Examination shows a positive anterior apprehension sign. Treatment at this time should consist of
. Putti-platt repair
. Open Bankart repair
. Injection of a subacromial corticosteroid
. Arthroscopic transglenoid capsular shift
. Rehabilitation of the scapular and rotator cuff muscles

Correct Answer & Explanation

. Putti-platt repair

Explanation

p.579: “The Putti-Platt procedure is contraindicated in multidirectional instability (AMBRI); tightening the front of the shoulder will only increase the likelihood of posterior instability. In traumatic instability (TUBS) the data suggest that such a procedure, which limits external rotation is not necessary if the Bankart lesion is solidly repaired.”p. 577: “A vigorous effort to stabilize the shoulder with exercises is particularly indicated in patients with multidirectional or posterior instability and in athletes requiring a completely normal or supranormal range of motion.”p. 989: “If the [swimmer] has symptoms of subluxation, a conservative program that strengthens the external rotators is warranted. Surgery is seldom indicated.”

Question 544

Topic: Shoulder & Hip Sports

A 22-year-old patient has had severe groin pain for many months and is unable to engage in any physical activity. The AP radiograph of the pelvis shows minimal arthritis. The lateral radiograph of the hip is shown in Figure 33a. An MR-arthrogram is shown in Figure 33b. What is the most appropriate treatment at this stage? Review Topic

. Hip arthroscopy and labral debridement
. Femoroacetabular osteoplasty and labral repair
. Femoral osteotomy
. Hemiarthroplasty
. Total hip arthroplasty

Correct Answer & Explanation

. Hip arthroscopy and labral debridement

Explanation

The patient has femoroacetabular impingement. The prominence on the femoral neck has resulted in a labral tear and detachment. An MR-arthrogram is the most appropriate modality for diagnosis of a labral tear. The diagnosis of a labral tear per se is not an indication for surgical intervention because the natural incidence of this condition is not known. Labral debridement without addressing the underlying anatomic abnormality is likely to result in a suboptimal outcome. The most appropriate treatment, when indicated, is shaving down of the femoral neck to remove the bony prominence and attachment of the labrum. Femoral osteotomy has no role in the treatment of this condition. The patient has minimal arthritis; therefore, arthroplasty is not indicated.

Question 545

Topic: Shoulder & Hip Sports
  • What location is the primary source of vascular ingrowth for tendon-bone healing with rotator cuff repair?
. Intra-articular bleeding
. Intratendinous layer of the rotator cuff
. Articular surface of the rotator cuff
. Holes in the greater tuberosity
. Bleeding from the decompressed acromion

Correct Answer & Explanation

. Intra-articular bleeding

Explanation

Question 546

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

Correct Answer & Explanation

. Rotator cuff tear

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.

Question 547

Topic: Shoulder & Hip Sports

Figure 1 is the T2 coronal MRI scan(Massive atraumatic rotator cuff tear) of a 52-year-old woman with a 6-month history of shoulder pain. She does not recall a history of trauma. Physical therapy is recommended. What is the most significant predictor of failure of nonoperative treatment?

. Tear size
. Pain scale score
. Strength deficit
. Patient expectations

Correct Answer & Explanation

. Tear size

Explanation

The MRI reveals a large full thickness supraspinatus tear. A large, prospective study showed that physical therapy can be effective in the treatment of atraumatic full-thickness rotator cuff tears. Patient expectations regarding the role of rehabilitation were the strongest predictor of surgery. Other factors associated with surgery were higher activity level and not smoking. Anatomic features of the rotatorcuff tear and the severity of patient’s reported pain did not predict failure of nonoperative treatment. Patients who have low expectations regarding the effectiveness of physical therapy are more likely to fail nonoperative treatment.

Question 548

Topic: Shoulder & Hip Sports

Which of the following statements best describes labral tears in the hip? Review Topic

. They are unrelated to degenerative joint disease.
. They lead to increased movement of the femur relative to the acetabulum.
. They usually result from lesions of the ligamentum teres.
. They only occur with abnormal bone morphology.
. They commonly occur in the posteroinferior quadrant of the hip.

Correct Answer & Explanation

. They lead to increased movement of the femur relative to the acetabulum.

Explanation

Labral and chondral lesions are observed within the anterosuperior quadrant of the acetabulum. Tearing of the labrum markedly reduces resistance to joint motion, leading to instability. The most common associated lesions are chondral injuries. They can occur with or without abnormal bone morphology. The etiology for labral tears can be from traumatic and degenerative causes, structural abnormalities from femoroacetabular impingement, developmental abnormalities, and hip instability.

Question 549

Topic: Shoulder & Hip Sports

Figure 1 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion with internal rotation and adduction reproduces his groin pain. Further workup confirms an anterosuperior tear of the acetabular labrum and prominence of the acetabulum. What is the most likely location of a chondral injury associated with these findings?

. Posterosuperior acetabulum
. Posteroinferior acetabulum
. Femoral head above the fovea
. Femoral head below the fovea

Correct Answer & Explanation

. Posteroinferior acetabulum

Explanation

This 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. Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasonography 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 in 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 hasimportant functions for hip stability and maintenance of the suction seal of the joint.

Question 550

Topic: Shoulder & Hip Sports

A 36-year-old softball player sustains a shoulder dislocation making a diving catch. The shoulder is successfully reduced in the emergency department. A postreduction MRI is shown in Figure 35. What anatomic lesion is a result of the dislocation? Review Topic

. Bankart lesion
. Humeral avulsion of the glenohumeral ligament (HAGL) lesion
. Superior labrum anterior-posterior (SLAP) lesion
. Hill-Sach deformity
. Glenoid fracture (bony Bankart)

Correct Answer & Explanation

. Bankart lesion

Explanation

The MRI scan reveals a HAGL lesion. It more commonly affects older patients and is associated with more violent trauma.

Question 551

Topic: Shoulder & Hip Sports

In recurrent posterior shoulder instability, what is the recommended approach to the posterior capsule? Review Topic

. A teres minor-splitting approach
. An infraspinatus-splitting approach
. Between the infraspinatus and teres minor
. Between the supraspinatus and infraspinatus
. In the rotator interval

Correct Answer & Explanation

. A teres minor-splitting approach

Explanation

Using an infraspinatus-splitting incision allows for excellent exposure of the posterior capsule and minimizes the risk of injury to the axillary nerve which lies inferior to the teres minor in the quadrilateral space.

Question 552

Topic: Shoulder & Hip Sports

What is the most specific physical examination finding? Review Topic

. Positive impingement sign
. Positive apprehension
. Positive active compression
. Weakness of external rotation
. Weakness of abduction

Correct Answer & Explanation

. Positive impingement sign

Explanation

Overhead athletes are prone to a number of problems involving the shoulder. Pitchers and volleyball players are susceptible to posterior superior labral tears and internal impingement. These patients will have posterior superior shoulder pain, a positive relocation sign, and a positive active compression test. Occasionally, these posterior superior labral tears are associated with a spinoglenoid cyst as seen in the MRI scan. These cysts cause compression of the suprascapular nerve which manifests primarily as weakness of the infraspinatus, resulting in weakness of external rotation.

Question 553

Topic: Shoulder & Hip Sports
Figure 1 shows the radiograph of a 71-year-old man who has had increasing pain and weakness in his shoulder for the past 3 years. Nonsurgical management has failed to provide relief. Examination shows 130 degrees of active forward flexion and intact external rotation strength. During surgery, a 1- x 1-cm rotator cuff tear involving the supraspinatus is encountered. Treatment should include:
. Humeral head replacement with rotator cuff repair
. Humeral head replacement without rotator cuff repair
. Arthrodesis of the shoulder
. Total shoulder replacement with rotator cuff repair
. Total shoulder replacement without rotator cuff repair

Correct Answer & Explanation

. Total shoulder replacement with rotator cuff repair

Explanation

Given the size of the rotator cuff tear, it is likely to be repaired; therefore, the treatment of choice is a total shoulder replacement with rotator cuff repair. Severe rotator cuff insufficiency can lead to early glenoid failure because of superior instability, and glenoid resurfacing should be avoided in those instances.

Question 554

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 49b, respectively. Which of the following best explains the 8-week postinjury clinical findings seen in Figure 49c?
. Axillary nerve palsy
. Spinal accessory nerve palsy
. Deltoid avulsion
. Rotator cuff tear
. Unreduced posterior glenohumeral dislocation

Correct Answer & Explanation

. Rotator cuff tear

Explanation

DISCUSSION: 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. REFERENCES: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 273-284. Neviaser RJ, Neviaser TJ, Neviaser JS: Anterior dislocation of the shoulder and rotator cuff rupture. Clin Orthop Relat Res 1993;291:103-106.

Question 555

Topic: Shoulder & Hip Sports

What is the most common physical finding in a patient with femoroacetabular impingement (FAI)? Review Topic

. Increased external rotation
. Increased abduction
. Decreased external rotation
. Decreased flexion and internal rotation
. Decreased adduction

Correct Answer & Explanation

. Increased external rotation

Explanation

A loss of flexion and internal rotation are hallmarks of FAI. With the hip flexed 90 degrees, maximal internal rotation testing is also known as the anterior impingement test, causing deep groin pain and reproduction of symptoms. Occasionally, a posterior impingement test will be positive with extension and external rotation. There are a variety of causes of FAI; however, the pathology limits motion as the femur (cam) and acetabulum (pincer) contact one another. Also, only one location needs to be present, such as cam-type or pincer-type versus both cam-pincer lesions to cause symptoms.

Question 556

Topic: Shoulder & Hip Sports
A 70-year-old man who underwent an uncomplicated large rotator cuff repair 6 months ago is now seeking a second opinion regarding persistent pain and weakness in his shoulder. Examination reveals that his incision is well healed and unreactive. The surgical report suggests that the tendons were secured back to bone with sutures through the greater tuberosity. Figure 28 shows a radiograph that was obtained 1 week ago. What is the most likely diagnosis?
. Infection
. Complex regional pain syndrome with associated osteopenia
. Frozen shoulder
. Failed rotator cuff repair
. Acromioclavicular joint arthritis

Correct Answer & Explanation

. Failed rotator cuff repair

Explanation

DISCUSSION: Symptoms can persist following a rotator cuff repair for a variety of reasons. In the early postoperative period, infection is the primary concern. Stiffness and loss of motion can occur because of postoperative scarring. Complex regional pain syndrome can occur but is rare, and the diagnosis is not made with a plain radiograph. This radiograph shows a superiorly migrated humeral head that articulates with the acromion, indicating that the repair has failed. While large to massive tears may fail more commonly than once thought, the clinical outcome may be satisfactory in many patients.

Question 557

Topic: Shoulder & Hip Sports
Based on the diagram shown in Figure 16, what muscle derives its innervation from the nerve identified by the letter “A”?
. Pectoralis minor
. Teres minor
. Subclavius
. Brachialis
. Supraspinatus

Correct Answer & Explanation

. Teres minor

Explanation

DISCUSSION: The nerve labeled A is the axillary nerve, a branch from the posterior cord. The posterior cord innervates the subscapularis, latissimus dorsi, teres major and minor, deltoid, triceps, anconeus, brachioradialis, and extensors of the forearm. The axillary nerve innervates the teres minor and deltoid. The pectoralis minor is innervated by the medial cord. The supraspinatus and the subclavius are innervated by the superior trunk. The brachialis is innervated by the lateral cord.

Question 558

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. Which of the four muscles of the rotator cuff provides the most resistance to this patient's direction of instability?

. Subscapularis
. Supraspinatus
. Infraspinatus
. Teres minor

Correct Answer & Explanation

. Subscapularis

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 isindicated. If a patient has excessive glenoid retroversion (not seen in this scenario with 5 degrees of retroversion), a posterior opening-wedge osteotomy is appropriate.

Question 559

Topic: Shoulder & Hip Sports

A 72-year-old woman was evaluated with an MRI scan for a shoulder mass that was confirmed to be a lipoma. Additional MRI findings included a 7-mm full-thickness tear of the supraspinatus tendon. Therefore, the patient was

. Observation
. Arthroscopic rotator cuff debridement
. Arthroscopic rotator cuff repair with acromioplasty
. Arthroscopic biceps tendon tenotomy
. Open rotator cuff repair with bone tunnels

Correct Answer & Explanation

. Observation

Explanation

In patients older than age 60 years, over 30% of asymptomatic shoulders show MRI findings of full-thickness rotator cuff tears. Therefore, without significant symptoms, surgical treatment is not warranted.

Question 560

Topic: Shoulder & Hip Sports
A 22-year-old swimmer underwent thermal capsulorrhaphy treatment for recurrent anterior subluxation. Following 3 weeks in a sling, an accelerated rehabilitation program allowed him to return to swimming in 3 1/2 months. While practicing the butterfly stroke, he sustained an anterior dislocation. He now continues to have symptoms of anterior instability and has elected to have further surgery. Surgical findings may include a
. biceps subluxation.
. glenoid rim fracture.
. subscapularis detachment.
. loose body.
. deficient anterior capsule.

Correct Answer & Explanation

. deficient anterior capsule.

Explanation

DISCUSSION: Complications of thermal capsule shrinkage or accelerated rehabilitation include capsule ablation. Since the original surgery did not include labral reattachment, findings of a Bankart lesion or a glenoid fracture from a nontraumatic injury are unlikely. Subscapularis detachment or biceps subluxation is a postoperative complication of open repairs. Failure of early postoperative instability treatment should not produce loose bodies. REFERENCES: Abrams JS: Thermal capsulorrhaphy for instability of the shoulder: Concerns and applications of the heat probe. Instr Course Lect 2001;50:29-36. Hecht P, Hayashi K, Lu Y, et al: Monopolar radiofrequency energy effects on joint capsular tissue: Potential treatment for joint instability. An in vivo mechanical, morphological, and biochemical study using an ovine model. Am J Sports Med 1999;27:761-771.

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