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Shoulder & Hip Sports MCQs

Practice Set 29 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 561

Topic: Shoulder & Hip Sports
If the site of the pathologic lesion is revealed in Figure 54f and not in Figure 54e after traumatic anterior shoulder dislocation, the mechanism of shoulder injury is likely
. axial loading of the glenohumeral joint.
. isolated hyperabduction.
. combined 45-degree abduction and external rotation.
. combined hyperabduction and external rotation.

Correct Answer & Explanation

. combined hyperabduction and external rotation.

Explanation

DISCUSSION: For patients with anterior shoulder instability, most commonly, a Bankart lesion, or detachment of the anteroinferior labrum with the attached inferior glenohumeral ligament from the glenoid rim is found. A medialized anteroinferior capsulolabral attachment (ALPSA lesion) is a common finding in shoulders with chronic anterior instability. The anterior band of the inferior glenohumeral ligament is tightest with the arm in 90 degrees of abduction with the shoulder externally rotated, creating a “hammock” that supports the humeral head. At 45 degrees of shoulder abduction, the capsuloligamentous components of the shoulder are at their loosest, resulting in the most total superior-inferior translation. During traumatic anterior glenohumeral dislocation, associated injuries commonly occur. Humeral avulsion of the glenohumeral ligaments (HAGL) has become a well-recognized cause of recurrent shoulder instability and is reported in 1% to 9% of patients. HAGL lesions can result from trauma in the setting of combined hyperabduction and external rotation. This is in contrast to a Bankart lesion, which is a result of trauma when the shoulder is hyperabducted without substantial associated rotation.

Question 562

Topic: Shoulder & Hip Sports
Figure 28 shows an arthroscopic view of a right shoulder in the lateral position through a posterior portal. What is the area between structure B (biceps) and SS (subscapularis tendon)?
. Inferior glenohumeral ligament
. Superior glenohumeral ligament
. Rotator cuff interval
. Subscapularis recess
. Interior recess

Correct Answer & Explanation

. Rotator cuff interval

Explanation

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

Question 563

Topic: Shoulder & Hip Sports
Figure 76 is the MR image of a 16-year-old high school football player who sustained a traumatic dominant shoulder dislocation during a game. On-field reduction was unsuccessful. The shoulder is reduced in the emergency department, and the player and his family follow up in clinic. Which factor is most associated with failure of surgical treatment in this scenario?
. Dominant shoulder
. Age
. Size of lesion
. Periosteal stripping

Correct Answer & Explanation

. Age

Explanation

DISCUSSION: The MR image reveals a Bankart lesion. Arthroscopic Bankart repair failure likelihood is increased by numerous factors. Age, number of recurrences, and bony defects are most associated with failure of arthroscopic repair. Shoulder dominance, amount of periosteal stripping, and difficulty of reduction do not correlate with increased recurrence risk following surgery.

Question 564

Topic: Shoulder & Hip Sports
What is the most common arthroscopic finding of internal impingement in an overhead athlete?
. Loose body
. Type III acromion
. Bankart lesion
. Rotator cuff articular side tear
. Biceps tendon fraying

Correct Answer & Explanation

. Rotator cuff articular side tear

Explanation

DISCUSSION: Internal impingement occurs when the articular side of the supraspinatus abrades against the posterior superior glenoid in the cocking position. Damage may include a posterior labral tear where the contact occurs, not anteriorly as in a Bankart lesion. Biceps fraying and acromion spurs are more commonly seen in extrinsic impingement. Loose bodies may occur from multiple lesions associated with instability and articular cartilage disorders but are uncommon in internal impingement. REFERENCES: Jobe CM: Posterior superior impingement of the rotator cuff on the glenoid rim as a cause of shoulder pain in the overhead athlete. Arthroscopy 1993;9:697-699. McFarland EG, Hsu C, Neir C, O’Neil O: Internal impingement of the shoulder: A clinical and arthroscopic analysis. J Shoulder Elbow Surg 1999;8:458-460.

Question 565

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?

. 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 <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 >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 566

Topic: Shoulder & Hip Sports

A 30-year-old man undergoes arthroscopic Bankart repair for recurrent anterior dislocation. He continues to experience instability postoperatively. Examination reveals a positive apprehension test. Radiographs of both shoulders are seen in Figure A. CT scan of his left shoulder is seen in Figure B. What is the best treatment option? Review Topic

. Bankart repair
. Humeral head bone augmentation
. Remplissage
. Coracoid autograft
. Connolly procedure

Correct Answer & Explanation

. Bankart repair

Explanation

This patient has anterior glenoid bone deficiency (inverted pear glenoid) from a large bony Bankart lesion that was not adequately addressed in the index procedure. This is best treated with bony augmentation using the Latarjet vascularized coracoid transfer.Patients with glenoid bone defects >20-30% have a high recurrence rate (>60%) after Bankart repair alone. Bone grafting is necessary to offer containment. Autograft options include coracoid transfer (such as the Latarjet procedure which extends the articular arc and creates a conjoined tendon sling) and iliac crest bone grafting.Burkhart et al. addressed glenohumeral bone defects. They advise that significant bone deficits cannot be adequately addressed via arthroscopic Bankart repair alone. The Latarjet transfer creates an extra-articular platform to extend the articular arc of the glenoid.Hantes et al. assessed Latarjet repairs using CT. They found that there is almostcomplete repair of a 25% to 30% glenoid defect when using the Latarjet procedure.Figure A comprises comparison Bernageau view glenoid profile radiographs of both shoulders. Figure B is a 3D reconstruction CT with showing glenoid bone deficiency (inverted pear deformity) with a large bony Bankart lesion. Illustration A shows the method of obtaining a Bernageau glenoid profile view. Illustration B shows the "cliff sign" of anterior glenoid bone loss. Illustration C depicts the Latarjet procedure. Illustration D depicts reduction in the articular arc with anterior glenoid loss.Incorrect Answers:

Question 567

Topic: Shoulder & Hip Sports

Figure 23 is the T2 axial MRI scan of a 21-year-old man who was injured while playing for his college football team. His pain was aggravated with blocking maneuvers and alleviated with rest, and he had to stop playing because of the pain. What examination maneuver most likely will reproduce his pain? Review Topic

. Forward elevation in the scapular plane
. External rotation and abduction
. Flexion, adduction, and internal rotation
. Flexion and abduction

Correct Answer & Explanation

. Forward elevation in the scapular plane

Explanation

This patient has a mechanism of injury and MRI consistent with a posterior labral tear and posterior instability. Flexion, adduction, and internal rotation produce a net posterior vector on the glenohumeral joint and should reproduce this patient's symptoms. Pain or instability with the arm elevated in the scapular plane describes an impingement sign. Pain or instability with the arm in external rotation and abduction describes the apprehension sign. Pain or instability with the arm in flexion and abduction is a nonspecific finding.

Question 568

Topic: Shoulder & Hip Sports
A 22-year-old wrestler who underwent an open anterior shoulder reconstruction to repair a dislocated shoulder 6 months ago now reports shoulder pain after attempting a takedown. Examination reveals external rotation that is 15 degrees greater than the contralateral side. He has pain associated with abduction and external rotation but no apprehension. Which of the following tests would most likely reveal positive findings?
. Impingement injection test
. Lift-off test
. Weakness with “empty-can” abduction test
. Load-and-sift maneuver
. MRI with contrast

Correct Answer & Explanation

. Lift-off test

Explanation

DISCUSSION: Postoperative subscapularis detachment can be identified with a positive lift-off test that reveals weakness in internal rotation. This complication does not necessarily compromise the anterior capsule repair. The load-and-sift maneuver and articular contrast studies may be normal. Supraspinatus tests for impingement and weakness should be negative.

Question 569

Topic: Shoulder & Hip Sports
A 72-year-old woman who was doing well after undergoing total shoulder arthroplasty for arthritis 4 months ago is suddenly unable to elevate her arm. Examination reveals 70 degrees of external rotation compared with 45 degrees on the uninvolved side, and she is unable to lift her hand off her lower back. Radiographs are shown in Figures 43a through 43c. Treatment should consist of
. Fascia lata graft to restore the coracoacromial arch.
. Immediate subscapularis repair.
. Revision arthroplasty with glenoid reaming to centralize the component.
. Revision arthroplasty with increased retroversion in the humeral component.
. Arthroscopic subacromial decompression.

Correct Answer & Explanation

. Immediate subscapularis repair.

Explanation

DISCUSSION: Results of treatment of subscapularis rupture are best when immediate repair is performed. When the cause of the anterior instability is the result of rupture of the subscapularis tendon and the component position is acceptable, revising the position of the component is unnecessary. Restoring the coracoacromial arch and subacromial decompression are related to superior instability and rotator cuff pathology, respectively, and would not correct the instability caused by subscapularis rupture.

Question 570

Topic: Shoulder & Hip Sports

The patient has weakness with elbow flexion and has numbness down the anterior lateral aspect of the forearm.

. Excessive medial placement of coracoid autograft
. Excessive lateral placement of coracoid autograft
. Excessive inferior dissection during the procedure
. Excessive retraction and dissection of the medial portion of the conjoint tendon

Correct Answer & Explanation

. Excessive retraction and dissection of the medial portion of the conjoint tendon

Explanation

DISCUSSIONThe Latarjet procedure was initially described in 1959 as a modification of the Bristow procedure. It has been used as a primary procedure to address instability, but is used more commonly for patients with instability and glenoid bone loss. In 2000, Burkhart and associates reported a 67% failure rate of the Bankart procedure in patients with an inverted pear-shaped glenoid (glenoid bone loss) or an engaging Hill-Sachs lesion, with a suggestion that a bone graft procedure would be optimal in this population. Complications following the Latarjet procedure have been reported as high as 25%, with the majority attributable to nerve injury, recurrent instability, and arthritis. Many of these complications are likely secondary to surgical technique. A coracoid graft that is placed too laterally or with prominent screws will overhang the glenoid and lead to early degenerative glenohumeral arthritis. A coracoid graft placed too medially can lead to recurrent instability secondary to an ineffective subscapularis sling and bone block. A coracoid graft placed inferiorly indicates dissection close to the axillary nerve, which can place tension on the axillary nerve or cause injury from direct trauma. After harvesting the coracoid graft, the surgeon must find the musculocutaneous nerve as it enters the conjoint tendon on the medial surface about 5 cm distal to the coracoid. Excessive dissection or retraction can lead to musculocutaneous nerve palsy.

Question 571

Topic: Shoulder & Hip Sports
Which of the following radiographic views best depicts a Hill-Sachs defect?
. Outlet
. True AP
. Serendipity
. Stryker notch
. Zanca

Correct Answer & Explanation

. Stryker notch

Explanation

The Stryker notch view best shows this type of defect. An outlet view helps evaluate acromial shape, a true AP shows joint space narrowing, a serendipity view evaluates the sternoclavicular joint, and a Zanca view helps evaluate the acromioclavicular joint. An internal rotation AP may also depict a Hill-Sachs defect.

Question 572

Topic: Shoulder & Hip Sports
In recurrent posterior shoulder instability, what is the recommended approach to the posterior capsule?
. 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

. An infraspinatus-splitting approach

Explanation

DISCUSSION: 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. REFERENCES: Dreese J, D’Alessandro D: Posterior capsulorrhaphy through infraspinatus split for posterior instability. Tech Shoulder Elbow Surg 2005;6:199-207. Shaffer BS, Conway J, Jobe FW, et al: Infraspinatus muscle-splitting incision in posterior shoulder surgery: An anatomic and electromyographic study. Am J Sports Med 1994;22:113-120. Fuchs B, Jost B, Gerber C: Posterior-inferior capsular shift for the treatment of recurrent voluntary posterior subluxation of the shoulder. J Bone Joint Surg Am 2000;82:16-25.

Question 573

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?
. 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

. Immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side.

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 574

Topic: Shoulder & Hip Sports

Figures 1 and 2 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 with traditional arthroscopic techniques when evaluating which outcome?

. Time to healing
. Retear rate
. Functional outcome scores
. Postsurgical pain scores

Correct Answer & Explanation

. Retear rate

Explanation

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 two techniques.

Question 575

Topic: Shoulder & Hip Sports
A 45-year-old right hand dominant female sustains a left shoulder injury after falling on ice 2 weeks ago. She is brought to the operating room for surgical intervention and positioned upright in a beach chair. Figures A and B are images taken from a posterior viewing portal with a 70-degree arthroscope. Figure C demonstrates the surgically repaired structure. Which of the following physical examination maneuvers would have been most likely abnormal in this patient preoperatively?
. Jerk Test
. Wright's Test
. Lift-off test
. Jobe's test
. Hornblower's test

Correct Answer & Explanation

. Lift-off test

Explanation

The repaired structure is the subscapularis tendon, tested frequently with the Lift-off test. Figure A as viewed from a posterior portal in the beach chair position of the left shoulder demonstrates a subscapularis tear with Figure B demonstrating medial instability of the long head of the biceps tendon. Figure C shows a repaired subscapularis to its footprint with double loaded screw-in anchors. A biceps tenodesis was concomitantly performed. The key physical exam findings are positive Belly-press and Lift-off maneuvers, as well as weakness in internal rotation and increased passive external rotation.

Question 576

Topic: Shoulder & Hip Sports

.A 22-year-old collegiate baseball pitcher has had posterior shoulder pain with decreased throwing velocity and accuracy over the past several months. Examination of the abducted shoulder in the supine position reveals 120 degrees of external rotation, 40 degrees of internal rotation on the throwing side, 100 degrees of external rotation, and 70 degrees of internal rotation on the nonthrowing side. The remainder of the clinical examination is unremarkable. An MRI scan shows a small partial articular-sided infraspinatus tear. Initial treatment should consist of

. arthroscopic rotator cuff repair.
. arthroscopic anterior capsulorrhaphy.
. arthroscopic selective posterior capsular release.
. selective posterior rotator cuff strengthening.
. posterior capsular stretching with scapular stabilization.

Correct Answer & Explanation

. arthroscopic rotator cuff repair.

Explanation

Question 577

Topic: Shoulder & Hip Sports

A 67-year-old female presents with shoulder pain for 3 months after falling down stairs. Imaging demonstrates a large rotator cuff tear involving multiple tendons. You perform an arthroscopic rotator cuff repair and biceps tenodesis. At her 2 month follow up, she reports worsening shoulder pain and decreased range of motion. Examination reveals active forward flexion to 80°. Passive range of motion is full. There is a positive external rotation lag sign. An MRI is performed and is pictured in Figure A. Which is the best treatment for this patient? Review Topic

. Revision repair of subscapularis
. Revision repair of infraspinatus
. Latissimus dorsi transfer
. Rotator interval release
. Total shoulder arthroplasty

Correct Answer & Explanation

. Revision repair of subscapularis

Explanation

The next best step for this patient's failed rotator cuff repair is a revision repair of the infraspinatus.Failed rotator cuff repair is multifactorial. Structural failure of repair is the result of both intrinsic and extrinsic factors. Intrinsic factors include advancing patient age, increasing tear size, poor tendon and muscle quality, systemic disease and smoking history. Extrinsic factors include inadequate biomechanical construct or repair configuration and overaggressive postoperative rehabilitation.Denard et al authored a review article on revision rotator cuff repair. Indications for revision repair are persistent symptoms despite nonoperative management in whom infection and advanced degenerative changes have been ruled out. Satisfactory results have been reported following revision repair of recurrent rotator cuff tears, particularly with arthroscopic techniques. Female sex and preoperative forward flexion < 135° is associated with poorer outcomes.Lambers Heerspink et al found that increasing age, larger tear size and additional biceps or acromioclavicular (AC) joint procedures have a negative influence on cuff integrity at follow up. Smoking, duration of symptoms, obesity and medical comorbidities were not found to influence cuff integrity in this study. Only AC procedures and workers’ compensation status were associated with worse functional outcomes.Figure A is a coronal T2 MRI demonstrating a failed rotator cuff repair with retear. Incorrect Responses:

Question 578

Topic: Shoulder & Hip Sports

A 62-year-old man has had worsening pain in the left shoulder for the past 6 weeks without trauma. He participated in physical therapy to "strengthen" his shoulder; however, it failed to provide relief. On examination, his right shoulder motion is 180, 60, and T8 (forward flexion, external rotation, and internal rotation). His left shoulder motion, both active and passive, is 150, 40, and L1. T1- and T2-weighted MRI scans are shown in Figures 106a and 106b with an official diagnosis of partial supraspinatus tendon tear. What is the appropriate treatment? Review Topic

. Physical therapy for rotator cuff strengthening and scapula stabilization
. Regimen of stretching exercises for motion
. Arthroscopic acromioplasty
. Arthroscopic acromioplasty and rotator cuff repair
. Open rotator cuff repair

Correct Answer & Explanation

. Physical therapy for rotator cuff strengthening and scapula stabilization

Explanation

The patient lacks both active and passive motion in all planes of shoulder motion; his primary pathology is adhesive capsulitis. Although the MRI scans reveal a partial-thickness rotator cuff tear, this is not uncommon in asymptomatic patients older than age 60 years. Physical therapy for patients with adhesive capulitis should stress shoulder motion rather than rotator cuff strengthening. Because most cases of adhesive capsulitis improve without surgical management, surgical treatment options are not appropriate at this time.

Question 579

Topic: Shoulder & Hip Sports

Figures 111a and 111b show axial MRI scans of a 24-year-old man who injured his right shoulder several years ago and now reports continued difficulty with the shoulder and has pain with activity. He reports that when the injury occurred, he felt that his shoulder "popped" but he never required closed reduction. He wore a

. Reaching back to hit a forehand in tennis
. External rotating the shoulder to spike a volleyball
. Performing a bench press with large amounts of weight
. Performing a biceps curl with large amounts of weights
. Throwing a baseball at the point of late cocking/early acceleration

Correct Answer & Explanation

. Reaching back to hit a forehand in tennis

Explanation

Performing a bench press with large amounts of weight is most likely to cause pain for a patient with a posterior labral tear. A patient who sustains a first-time posterior dislocation is less likely to have recurrent dislocations compared with first-time anterior dislocations. Patients often do have problems with loading the shoulder in a forward flexed position, such as during a bench press. The other activities listed here might be difficult, but are not as likely to be problematic. A biceps curl might bother a person with a SLAP tear. The late cocking/early acceleration phase of throwing, the overhead portion of a tennis serve, and spiking a volleyball places the shoulder in an abduction/external rotation position, which is likely to be problematic for a person with anterior instability.

Question 580

Topic: Shoulder & Hip Sports

A 23-year-old right-hand dominant professional baseball pitcher has right shoulder pain when releasing the ball. He has noticed his velocity has decreased over the past 2 months. Examination reveals supine abducted external rotation of 110 degrees compared to 100 degrees on the left side. His internal rotation is 30 degrees on the right compared to 70 degrees on the left side. Rotator cuff strength is normal. All other clinical tests are normal. MRI with contrast reveals no intra-articular lesions. What is the best course of treatment? Review Topic

. Arthroscopic capsular plication
. Arthroscopic thermal shift
. Arthroscopic subacromial decompression
. Posterior capsular stretching
. Selective external rotation stretching

Correct Answer & Explanation

. Arthroscopic capsular plication

Explanation

The examination reveals that the patient has posterior capsular tightness. Surgery should not be considered until the patient has failed to respond to nonsurgical management. The internal rotation contracture (GIRD - glenohumeral internal rotation deficit) should be addressed with appropriate posterior capsular stretching. Thisshould then be followed by appropriate rotator cuff and scapular stabilization exercises. Only if this management fails to relieve the patient's symptoms should surgery be considered. This patient clearly does not need external rotation stretching given the fact that he has normal external rotation.

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