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Shoulder & Hip Sports MCQs

Practice Set 30 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 581

Topic: Shoulder & Hip Sports

-Figures a through c are the MRI scans of a 21-year-old woman with recurrent shoulder instability and pain after an open anterior stabilization procedure. Positive belly-press test findings were positive.At surgery she was found to have an irreparable tear of the tendon injury identified preoperatively. The procedure to address the dynamic stabilizer deficit places which nerve at most risk?

. Ulnar
. Radial
. Axillary
. Median
. Musculocutaneous

Correct Answer & Explanation

. Ulnar

Explanation

Question 582

Topic: Shoulder & Hip Sports

A patient has multidirectional instability of the shoulder that has not responded to nonsurgical management. Successful surgical treatment will most likely include which of the following? Review Topic

. Abrasion arthroplasty of the anterior glenoid rim
. Posterior capsular advancement into a Hill-Sachs defect
. Repair of an inferior glenohumeral ligament detachment
. Repair of an unstable SLAP tear
. Closure of the rotator interval

Correct Answer & Explanation

. Abrasion arthroplasty of the anterior glenoid rim

Explanation

Published reports establish the importance of the rotator interval in shoulder stability and improvements achieved through suture closure of the interval. Multidirectionalinstability treated surgically following failure to respond to nonsurgical management has been shown to be associated with classic Bankart lesions, Hill-Sachs defects, glenoid chondral lesions, and even SLAP lesions (Werner). However, these lesions were seen in a lower percentage than that found for unidirectional anterior dislocations. Likewise, these lesions do not appear to be significant in influencing treatment in the majority of patients.

Question 583

Topic: Shoulder & Hip Sports
Figure 30 shows an axial T1-weighted MRI scan of a patient’s right shoulder. The arrows are pointing to what normal structure?
. Deltoid insertion
. Subscapularis tendon
. Latissimus dorsi tendon
. Short head of the biceps tendon
. Pectoralis major tendon

Correct Answer & Explanation

. Pectoralis major tendon

Explanation

Tears of the pectoralis major tendon are frequently missed during examination. MRI provides excellent visualization of the tendon if the study extends low enough down the arm. The pectoralis major tendon inserts on the crest of the greater tubercle of the humerus, just lateral to the long head of the biceps tendon. The latissimus dorsi tendon inserts medial to the long head of the biceps tendon on the lesser tubercle. The subscapularis tendon inserts on the lesser tuberosity more proximally. The deltoid insertion is more distal.

Question 584

Topic: Shoulder & Hip Sports

Which of the follow scenarios is most likely to be amenable to a complete repair of a massive rotator cuff tear? Review Topic

. year-old woman with rheumatoid arthritis
. year-old man with a tear associated with an anterior shoulder dislocation
. year-old man who underwent repair of an ipsilateral rotator cuff 3 years ago
. year-old male laborer with superior humeral migration on radiographs
. year-old woman with muscular atrophy noted in the supraspinatus fossa

Correct Answer & Explanation

. year-old woman with rheumatoid arthritis

Explanation

Whereas a rotator cuff tear associated with an acute anterior dislocation in 45-year old patient may be massive, its acute nature typically means that significant retraction and atrophy of the musculature has not occurred. Therefore, repair is often complete and tension-free. A massive tear associated with rheumatoid arthritis is likely one of chronic attrition with poor tendon tissue because of the underlying disease and chronic corticosteroid use. Repairs of massive chronic rotator cuff tears have been reported to have a 50% rate of retear and this rate would be expected to be higher in the revision setting and with evident supraspinatus atrophy on physical examination. Superior humeral migration on static upright radiographs indicates loss of the superior glenoid rim, leading to rotator cuff tear arthropathy.

Question 585

Topic: Shoulder & Hip Sports
A patient reports pain in the hip with functional positioning. With the patient supine, pain in which of the following positions would be typical for femoral acetabular impingement?
. Hip is internally rotated, passively flexed to 90 degrees, and adducted
. Hip is internally rotated, passively flexed to 90 degrees, and abducted
. Hip is externally rotated, maximally flexed to 90 degrees, and adducted
. Hip is externally rotated, passively flexed to 90 degrees, and abducted
. Hip is externally rotated, maximally flexed, and abducted

Correct Answer & Explanation

. Hip is internally rotated, passively flexed to 90 degrees, and adducted

Explanation

DISCUSSION: Patients with dysplasia often have a hypertrophic labrum. Abnormal contact between the femoral neck and the acetabular rim leads to labral injury, especially in the anterior-superior acetabular zone. Typically, young patients with the condition report pain with activity or long periods of sitting or driving. The hips often have limited motion, in particular in internal rotation and flexion. Forceful adduction with the maneuver causes pain. REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 411-424. Beck M, Leunig M, Parvizi J, et al: Anterior femoroacetabular impingement: Part II. Midterm results of surgical treatment. Clin Orthop 2004;418:67-73. McCarthy JC, Noble PC, Schuck MR, et al: The role of labral lesions to development of early degenerative hip disease. Clin Orthop 2001;393:25-37.

Question 586

Topic: Shoulder & Hip Sports
A 60-year-old right hand-dominant woman fell on her outstretched arm and sustained an anterior shoulder dislocation. The shoulder is reduced in the emergency department and she is seen for follow-up 1 week later wearing a sling. Examination reveals that she has significant difficulty raising her arm in forward elevation and has excessive external rotation compared to the contralateral shoulder. What is the next most appropriate step in management?
. MRI
. Electromyography
. Open repair of the supraspinatus
. Arthrography
. Arthroscopic labral repair

Correct Answer & Explanation

. MRI

Explanation

DISCUSSION: In patients older than age 40 years, a high suspicion of a rotator cuff tear should be kept in those patients with weakness after shoulder dislocation. Both posterior rotator cuff and subscapularis injuries have been documented. The next most appropriate step in management should be MRI. If the findings are negative, suspicion of nerve injury should lead to electromyography. REFERENCES: Stayner LR, Cumming J, Andersen J, et al: Shoulder dislocations in patients older than 40 years of age. Orthop Clin North Am 2000;31:231-239. Neviaser RJ, Neviaser TJ, Neviaser JS: Concurrent rupture of the rotator cuff and anterior dislocation of the shoulder in the older patient. J Bone Joint Surg Am 1988;70:1308-1311.

Question 587

Topic: Shoulder & Hip Sports

Recent randomized controlled trials comparing early passive range of motion to 6 weeks of immobilization after successful arthroscopic rotator cuff repair concluded that, compared to immobilization, early passive range of motion resulted in: Review Topic

. Higher Constant scores at 12 months
. Increased rates of re-rupture as determined by ultrasound
. Equivalent functional outcomes
. Less pain at 6 months
. Inceased range of motion at 12 months

Correct Answer & Explanation

. Higher Constant scores at 12 months

Explanation

A series of high-quality RCTs have demonstrated that early passive range of motion has equivalent functional outcomes when compared to 6 weeks of immobilization after arthroscopic rotator cuff surgery.Traditionally, most surgeons recommended early post-operative range of motion exercises for their patients in order to prevent adhesions and ultimately stiffness. However, recent evidence has found that there is no difference in the healing rate, range of motion or functional outcome between patients who undergo early versus delayed (i.e. initial 6 weeks of immobilization) passive range of motion exercises after arthroscopic rotator cuff repair.Kim et al. conducted a randomized controlled trial comparing early passive range of motion vs. immobilization in 106 patients who underwent arthroscopic repair for full-thickness rotator cuff tears. They found that there was no clinically or statistically significant difference between the two groups in pain, healing or function.Keener et al. also conducted a randomized controlled trial of 124 patients who were undergoing arthroscopic repair of a full-thickness rotator cuff tear and found no difference between early and delayed range of motion in healing and functional outcome.Cuff & Pupello also compared early vs. delayed range of motion during the postoperative rehabilitation phase in a randomized controlled trial of 68 individuals undergoing arthroscopic rotator cuff repair and found no significant difference in range of motion or healing.Incorrect Answers:

Question 588

Topic: Shoulder & Hip Sports
A patient reports persistent anterior shoulder pain following a forceful external rotation injury to the shoulder. An MRI scan is shown in Figure 4. The patient remains symptomatic despite 3 months of nonsurgical management. Treatment should now consist of:
. repair of the superior labrum.
. isolated supraspinatus repair.
. biceps recentering.
. subscapularis repair and biceps tenodesis.
. subscapularis repair and recentering of the biceps tendon.

Correct Answer & Explanation

. subscapularis repair and biceps tenodesis.

Explanation

DISCUSSION: The MRI scan reveals a subscapularis tear with a biceps that is out of the groove. Treatment in this patient is most predictable if the subscapularis is repaired. The biceps should either be tenodesed or tenotomized since it is unstable. Recentering of the biceps has been found to be unpredictable. Treatment of these lesions has been shown to have better results if the biceps is either released or tenodesed. This prevents recurrent biceps symptoms that can be a source of surgical failure. REFERENCES: Edwards TB, Walch G, Sirvenaux F, et al: Repair of tears of the subscapularis: Surgical technique. J Bone Joint Surg Am 2006;88:1-10. Deutsch A, Altcheck DW, Veltri DM, et al: Traumatic tears of the subscapularis tendon: Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Am J Sports Med 1997;25:13-22. Walch G, Nove-Josserand L, Boileau P, et al: Subluxations and dislocations of the tendon of the long head of the biceps. J Shoulder Elbow Surg 1998;7:100-108.

Question 589

Topic: Shoulder & Hip Sports
A patient who sustained a cerebrovascular accident (CVA) 18 months ago has a long-standing spastic adduction contracture of the shoulder with a rigid block to passive external rotation. Significant hygiene problems exist with maceration and continued skin breakdown. Management should consist of:
. a percutaneous pectoralis tenotomy.
. a modified L’Episcopo procedure.
. serial lidocaine nerve blocks.
. pectoralis tenotomy and subscapularis tendon lengthening.
. phenol nerve blocks.

Correct Answer & Explanation

. pectoralis tenotomy and subscapularis tendon lengthening.

Explanation

DISCUSSION: Following a CVA, the muscular imbalance often leads to a fixed contracture of the shoulder in adduction, internal rotation, and flexion. The responsible muscles include the pectoralis major, subscapularis, teres major, and latissimus dorsi. If stretching cannot produce enough improvement for axillary hygiene, then surgery is an option. If the shoulder resists external rotation during examination with the arm at the side, as in this patient, then the subscapularis is spastic and contributing to the deformity as well and needs to be released along with the pectoralis. Phenol nerve blocks are most effective and best given within 6 months of the initial CVA to be effective. Lidocaine blocks may be helpful in determining whether a deformity is caused by a fixed soft-tissue contracture or by spasticity but play no role once the contracture is present. The modified L’Episcopo procedure is indicated in patients with contracture secondary to brachial plexus birth palsies. REFERENCES: Braun RM, Botte MJ: Treatment of shoulder deformity in acquired spasticity. Clin Orthop 1999;368:54-65. McCollough NC III: Orthopaedic evaluation and treatment of the stroke patient. Instr Course Lect 1975;24:45-55.

Question 590

Topic: Shoulder & Hip Sports

Biomechanical in vitro studies of double-row anchor fixation of rotator cuff tears show what initial advantage over single-row anchor fixation? Review Topic

. Increased peak-to-peak elongation
. Decreased stiffness
. Higher ultimate tensile load
. Decreased contact area
. Increased conditioning elongation

Correct Answer & Explanation

. Higher ultimate tensile load

Explanation

Biomechanical in vitro studies of double-row fixation of rotator cuff tears during cyclic loading and tensile loading to failure have demonstrated that double-row fixation results in a higher ultimate tensile load when compared to single-row fixation. Peak-to-peak elongation, stiffness, and conditioning elongation for double-row fixation were all similar to single-row fixation. These initial findings, however, may or may not lead to improved clinical outcomes.

Question 591

Topic: Shoulder & Hip Sports

Figures 1 and 2 are the CT and MRI scans of a patient with shoulder instability. 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 scans represent better definition of bone loss than two-dimensional MRI 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. 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.

Correct Answer & Explanation

. Both CT and MRI have equivalent cost for the patient.

Explanation

A 43-year-old woman is involved in a motor vehicle collision. She sustains the isolated injury shown in the radiograph in Figure 1. Her neurovascular examination is compromised. What is the most likely deficit?A. Inability to flex the distal interphalangeal joint of the index fingerB. Positive Froment’s signC. Weakness with wrist extensionD. Decreased capillary refill

Question 592

Topic: Shoulder & Hip Sports

A 47-year-old man who is an avid tennis player and laborer has had one year of shoulder pain and weakness. His pain occurs at night and radiates to the deltoid laterally. The patient denies any anterior based pain. He reports no prior surgeries and has been managed with steroid injections and physical therapy. On examination, he has full passive motion with significant weakness with external rotation. His neurologic examination is unremarkable. MRI evaluation reveals a posterior-superior rotator cuff tear with Goutallier grade 4 fatty infiltrate in the supraspinatus and infraspinatus with retraction beyond the glenoid. He is concerned about the lack of rotation of his arm and reports that this disability creates significant disability with his occupation as a mason. What is the best next step?

. Shoulder scope and subacromial decompression
. Tendon transfer
. Total shoulder arthroplasty
. Reverse total shoulder arthroplasty

Correct Answer & Explanation

. Tendon transfer

Explanation

In younger active patients, tendon transfer is considered a preferable treatment option. The patient has failed a course of nonoperative management. Subacromial decompression may offer pain relief but may not be advisable in a patient with rotator cuff deficient shoulder. A total shoulder arthroplasty requires functionality of the supraspinatus and infraspinatus. A reverse total shoulder is an option to alleviate pain and perhaps improve forward flexion height and strength; however, reverse arthroplasty would not improve external rotation in this patient, and there is concern for longevity of the implant in youngerpatient populations.

Question 593

Topic: Shoulder & Hip Sports

A 25-year-old lineman is referred to your office for a second opinion. 1 year ago, he underwent an arthroscopic procedure for shoulder instability. He complains of persistent sense of instability despite the surgery. Which of the following is a contraindication to revision arthroscopic labral repair for recurrent anterior glenohumeral instability? Review Topic

. Glenoid bone loss of 10%
. Capsular attenuation from prior thermal capsulorraphy
. Anterior labral periosteal sleeve avulsion (ALSPA ) lesion
. Glenoid labral articular defect (GLAD) lesion
. Combined Superior Labrum from Anterior to Posterior tear (SLAP) and recurrent Bankart lesion

Correct Answer & Explanation

. Capsular attenuation from prior thermal capsulorraphy

Explanation

Capsular attenuation or postthermal capsular necrosis from prior thermal capsulorraphy is a contraindicated to arthroscopic repair.Thermal capsulorrhaphy utilizes heat generated by radiofrequency or laser ablation to cause capsular shrinkage in an effort to treat shoulder instability. However, high recurrence rates have been found, especially around two to three weeks after the index procedure, when the capsular tissue is the weakest. In the setting of recurrence following thermal capsulorrhaphy, open revision is recommended.Creighton et al. reported on a series of 18 patients undergoing revision arthroscopic stabilization. Of the 18, 3 failed with recurrent instability, all with previous thermal capsulorrhaphy.Miniaci et al. reviewed the outcomes following thermal capsulorrhaphy noting high rates of recurrent instability, especially in the setting of initial treatment for multidirectional instability.Park et al. reported on a series of 14 patients undergoing revision following thermal capsulorrhaphy. Ten out of 14 patients had signs of capsular thinning, insufficiency and attenuation.Wong et al. surveyed 379 shoulder surgeons on the complications following thermal capsulorrhaphy. Capsular insufficiency and thinning were commonly associated with recurrent instability.Hecht et al. performed thermal capsulorrhaphy and biomechanical analysis of the capsule in a sheep model. The authors found that the capsule was weakest at the 2-3 week post-operative timepoint, leading to the highest rate insufficiency, attenuation and mechanical failure at this time.Incorrect answers:

Question 594

Topic: Shoulder & Hip Sports

Figure 55 shows the radiograph of a 30-year-old man who sustained a closed comminuted fracture of the right clavicle. Examination reveals decreased sensation in the radial nerve distribution. Weakness is noted with shoulder abduction, internal rotation, and wrist extension. A displaced bone fragment is most likely pressing on what portion of the brachial plexus? Review Topic

. C5 and C6 spinal roots
. Superior trunk
. Anterior division of the inferior trunk
. Posterior cord
. Lateral and posterior cords

Correct Answer & Explanation

. Posterior cord

Explanation

Clavicular fractures are occasionally complicated by injury to the brachial plexus. A displaced bone fragment pressing on the posterior cord proximal to the upper subscapularis nerve would account for these findings.

Question 595

Topic: Shoulder & Hip Sports
A 21-year-old pitcher reports shoulder pain with hard throwing. He notes that the pain occurs in the early acceleration phase of his throw. Given his history, what structures are at greatest risk for injury?
. Posterosuperior labrum, greater tuberosity, articular side of the rotator cuff
. Posterior glenoid, humeral head, bursal side of the rotator cuff
. Biceps anchor, articular side of the rotator cuff, supraspinatus tendon
. Biceps tendon, bursal side of the rotator cuff, superior labrum
. Subscapularis, anterior labrum, humeral head

Correct Answer & Explanation

. Posterosuperior labrum, greater tuberosity, articular side of the rotator cuff

Explanation

DISCUSSION: Internal impingement in the thrower’s shoulder occurs in the abducted, externally rotated position as described by Walch and associates. The injury is thought to occur from repetitive contact between the posterosuperior portion of the labrum and glenoid against the articular side of the rotator cuff and greater tuberosity. REFERENCES: Paley KJ, Jobe FW, Pink MM, et al: Arthroscopic findings in the overhand throwing athlete: Evidence for posterior internal impingement of the rotator cuff. Arthroscopy 2000;16:35-40. Jazrawi LM, McCluskey GM III, Andrews JR: Superior labral anterior and posterior lesions and internal impingement in the overhead athlete. Instr Course Lect 2003;52:43-63. Walch G, Boileau P, Noel E, et al: Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: An arthroscopic study. J Shoulder Elbow Surg 1992;1:238-245.

Question 596

Topic: Shoulder & Hip Sports
What is the most common result if the acetabulum is rotated too far anteriorly during a periacetabular osteotomy?
. Posterior dislocation
. Limited hip flexion
. Heterotopic ossification
. Femoral nerve injury
. Fracture of the posterior column

Correct Answer & Explanation

. Limited hip flexion

Explanation

DISCUSSION: In patients with hip dysplasia who undergo a periacetabular osteotomy, the authors note that the freed acetabular segment can be overcorrected for the deformity. If it is placed too anteriorly, then hip flexion is limited. Posterior dislocation is a rare complication. The other complications should not occur as a result of this procedure. REFERENCES: Hussell JG, Rodriguez JA, Ganz R: Technical complications of the Bernese periacetabular osteotomy. Clin Orthop 1999;363:81-92. Myers SR, Eijer H, Ganz R: Anterior femoroacetabular impingement after periacetabular osteotomy. Clin Orthop 1999;363:93-99.

Question 597

Topic: Shoulder & Hip Sports

Figure 40 shows the MRI scan of a 23-year-old man with a history of recurrent anterior shoulder instability. What is the most likely diagnosis? Review Topic

. Humeral avulsion of the inferior glenohumeral ligament (HAGL lesion)
. Osseous Bankart lesion
. Perthes lesion
. Anterior labroligamentous periosteal sleeve avulsion (ALPSA lesion)
. Glenolabral articular disruption (GLAD lesion)

Correct Answer & Explanation

. Humeral avulsion of the inferior glenohumeral ligament (HAGL lesion)

Explanation

The MRI scan shows an ALPSA lesion. This is also known as a medialized Bankart with medial displacement of the torn anterior labrum. During surgical stabilization, the labrum and periosteal sleeve must be mobilized and repaired laterally to reduce recurrent instability. A Perthes lesion is a nondisplaced labral tear. A GLAD lesion represents a nondisplaced anterior labral tear with an associated articular cartilage injury.

Question 598

Topic: Shoulder & Hip Sports

What is the primary sign/symptom with unidirectional posterior instability of the shoulder? Review Topic

. Instability
. Dead arm symptoms
. Locking or catching
. Decreased range of motion
. Pain

Correct Answer & Explanation

. Instability

Explanation

Posterior labral tears and pathology are usually associated with recurrent chronic injury to the shoulder. Situations such as blocking in football load the humeral head posteriorly, and may predispose to posterior labral injury. Unlike anterior and superior labral pathology, symptoms of posterior labral tears are often vague, though pain with activity is most common. Instability is usually associated with anterior labral pathology. Dead arm symptoms are associated with anterior and superior pathology, especially in throwers. Mechanical locking and catching are less common for any labral pathology. Range of motion with posterior labral pathology is usually unaffected.

Question 599

Topic: Shoulder & Hip Sports

Which of the following 50-year-old patients with an irreparable rotator cuff tendon is the best candidate for an isolated latissimus dorsi muscle transfer? Review Topic

. Man with active elevation to 90 degrees
. Woman with active elevation to 45 degrees
. Woman with a Hornblower's sign (complete absence of external rotation with abduction)
. Man with superior escape of the humeral head
. Man with full motion and a positive lift-off test

Correct Answer & Explanation

. Man with active elevation to 90 degrees

Explanation

Patients with superior escape or a torn subscapularis (demonstrated by a positive lift-off test) will not benefit from a latissimus dorsi transfer, even if combined with a pectoralis muscle transfer. In the study by Iannotti and associates, women had poorer outcomes than men, and patients with preoperative elevation below shoulder level or 90 degrees also had poorer outcomes. Patients with complete loss of external rotator function have worse function after latissimus dorsi transfer than patients with some external rotation function.

Question 600

Topic: Shoulder & Hip Sports
Figure 14 shows an intra-articular gadolinium-enhanced MRI scan of a 52-year-old woman who has stopped playing tennis because of pain in her left shoulder while serving. What is the most likely diagnosis?
. Superior labral detachment
. Os acromiale
. Partial-thickness rotator cuff tear on the articular side
. Medial subluxation of the long head of the biceps
. Moderate arthrosis of the glenohumeral joint

Correct Answer & Explanation

. Partial-thickness rotator cuff tear on the articular side

Explanation

DISCUSSION: The MRI scan shows increased signal intensity along the deep fibers of the supraspinatus near its insertion. This is typical of tendinosis and a probable partial-thickness rotator cuff tear.

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