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Shoulder & Hip Sports MCQs

Practice Set 31 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 601

Topic: Shoulder & Hip Sports

A 22-year-old rugby player presents with recurrent anterior shoulder instability. A 3D CT scan demonstrates 25% anterior glenoid bone loss and an engaging Hill-Sachs lesion. What is the most appropriate surgical management?

. Arthroscopic Bankart repair
. Arthroscopic Bankart repair with Remplissage
. Open Latarjet procedure
. Open Bankart repair
. Proximal humerus derotational osteotomy

Correct Answer & Explanation

. Arthroscopic Bankart repair

Explanation

For critical anterior glenoid bone loss (generally >20-25%) in a high-demand collision athlete, an arthroscopic or open Bankart repair has an unacceptably high failure rate. A coracoid transfer (Latarjet) is indicated to restore the glenoid arc and provide the dynamic 'sling' effect of the conjoint tendon.

Question 602

Topic: Shoulder & Hip Sports

A 38-year-old female presents with chronic groin pain exacerbated by hip flexion and internal rotation. An AP pelvis radiograph reveals a 'crossover sign.' What underlying pathomorphology does this indicate, and what type of impingement is most likely?

. Retroverted acetabulum; Cam impingement
. Anteverted acetabulum; Pincer impingement
. Retroverted acetabulum; Pincer impingement
. Decreased femoral head-neck offset; Cam impingement
. Coxa profunda; Cam impingement

Correct Answer & Explanation

. Retroverted acetabulum; Cam impingement

Explanation

The 'crossover sign' is visible on an AP pelvis radiograph when the anterior wall of the acetabulum crosses lateral to the posterior wall. This indicates cranial acetabular retroversion, leading to anterior overcoverage of the femoral head. It is a classic radiographic hallmark of Pincer-type femoroacetabular impingement (FAI).

Question 603

Topic: Shoulder & Hip Sports

A 45-year-old laborer has an irreparable posterosuperior rotator cuff tear with an intact subscapularis, severe external rotation lag, and a positive hornblower's sign. There is no glenohumeral arthritis. Which tendon transfer is most biomechanically appropriate to restore external rotation?

. Pectoralis major
. Latissimus dorsi
. Lower trapezius
. Biceps brachii
. Teres major

Correct Answer & Explanation

. Pectoralis major

Explanation

For an irreparable posterosuperior cuff tear with profound external rotation weakness (hornblower's sign indicates teres minor deficiency) and an intact subscapularis, restoring external rotation is paramount. The lower trapezius tendon transfer, often augmented with an Achilles tendon allograft, most closely replicates the force vector of the infraspinatus. Latissimus dorsi is also an option but historically has variable outcomes for pure ER restoration compared to lower trapezius.

Question 604

Topic: Shoulder & Hip Sports

In the pathophysiology of Cam-type femoroacetabular impingement (FAI), which of the following best describes the primary mechanism of chondral injury?

. Linear contact between the acetabular rim and the femoral neck causing 'contrecoup' posterior cartilage damage
. Outside-in abrasive wear of the posterior acetabular cartilage
. Shear forces generated by an aspherical femoral head entering the acetabulum causing anterosuperior chondral delamination
. Global pincer-type overcoverage causing circumferential labral ossification
. Pincer impingement leading to isolated ligamentum teres avulsion

Correct Answer & Explanation

. Shear forces generated by an aspherical femoral head entering the acetabulum causing anterosuperior chondral delamination

Explanation

Cam FAI is characterized by an aspherical femoral head (decreased head-neck offset) that forces its way into the acetabulum during flexion. This generates significant shear forces at the anterosuperior acetabulum, tearing the labrum from the transitional cartilage and causing an 'inside-out' delamination of the articular cartilage. Contrecoup lesions are typically seen in Pincer impingement.

Question 605

Topic: Shoulder & Hip Sports

A 28-year-old female presents with deep groin pain exacerbated by hip flexion and internal rotation. An AP pelvis radiograph demonstrates a 'cross-over sign'. What type of femoroacetabular impingement and anatomical abnormality does this represent?

. Cam impingement due to a decreased femoral head-neck offset
. Pincer impingement due to focal acetabular retroversion
. Cam impingement due to an aspherical femoral head
. Pincer impingement due to coxa profunda
. Pincer impingement due to global acetabular anteversion

Correct Answer & Explanation

. Pincer impingement due to focal acetabular retroversion

Explanation

The 'cross-over sign' occurs when the anterior wall of the acetabulum projects lateral to the posterior wall on an AP radiograph. This indicates cranial or focal acetabular retroversion, which leads to pincer-type impingement.

Question 606

Topic: Shoulder & Hip Sports

A 25-year-old baseball pitcher complains of vague posterior shoulder pain and weakness in external rotation. Examination shows isolated atrophy of the infraspinatus with normal supraspinatus bulk. A paralabral cyst is suspected. Where is the cyst most likely located?

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

Correct Answer & Explanation

. Spinoglenoid notch

Explanation

Compression of the suprascapular nerve at the spinoglenoid notch affects only the motor branch to the infraspinatus. Compression at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 607

Topic: Shoulder & Hip Sports

A 65-year-old male presents with an irreparable subscapularis tear and recurrent anterior shoulder instability. The posterosuperior rotator cuff is intact. Which tendon transfer is most biomechanically appropriate to restore anterior shoulder stability and internal rotation?

. Latissimus dorsi transfer
. Lower trapezius transfer
. Pectoralis major transfer
. Teres major transfer

Correct Answer & Explanation

. Pectoralis major transfer

Explanation

The pectoralis major transfer (either split or entire tendon) is the preferred procedure for irreparable subscapularis tears. It best replicates the vector of the subscapularis to provide anterior stability and internal rotation.

Question 608

Topic: Shoulder & Hip Sports

A 28-year-old male undergoes arthroscopic osteochondroplasty for femoroacetabular impingement (FAI) due to a large CAM lesion. Over-resection of the anterolateral femoral head-neck junction places the patient at greatest risk for which devastating complication?

. Heterotopic ossification
. Avascular necrosis of the femoral head
. Femoral neck fracture
. Sciatic nerve injury

Correct Answer & Explanation

. Heterotopic ossification

Explanation

Resecting more than 30% of the anterolateral femoral neck diameter significantly alters the biomechanics and dramatically increases the risk of a postoperative iatrogenic femoral neck fracture.

Question 609

Topic: Shoulder & Hip Sports

A 24-year-old elite baseball pitcher presents with posterior shoulder pain during the late cocking phase. MRI reveals a partial articular-sided supraspinatus tendon avulsion (PASTA) and a superior labrum anterior-posterior (SLAP) tear. This specific triad of "internal impingement" is most strongly associated with which clinical finding?

. Glenohumeral internal rotation deficit (GIRD)
. Anterior capsular laxity
. Scapular winging
. Isolated subscapularis weakness

Correct Answer & Explanation

. Glenohumeral internal rotation deficit (GIRD)

Explanation

Internal impingement in overhead throwing athletes (PASTA lesion, SLAP tear, posterior shoulder pain) is biomechanically driven by a tight posterior capsule, which clinically presents as Glenohumeral Internal Rotation Deficit (GIRD).

Question 610

Topic: Shoulder & Hip Sports

A 23-year-old woman with recurrent anterior instability undergoes an open Bankart procedure. Six months after surgery the patient reports shoulder

. Physical therapy
. Biceps tenolysis
. Subscapularis repair
. Supraspinatus repair
. Pectoralis major repair

Correct Answer & Explanation

. Physical therapy

Explanation

The axial MRI scan shows rupture of the subscapularis tendon with dislocation of the biceps tendon. Treatment should include a biceps tenotomy or tenodesis in conjunction with a subscapularis repair. A pectoralis major transfer may be necessary in chronic cases where the subscapularis is irreparable, but in this patient the tendon is repairable. As a single operation, biceps tenolysis will not correct the instability, and would likely result in a cosmetic deformity. Physical therapy will not restore subscapularis function.

Question 611

Topic: Shoulder & Hip Sports

What is the most likely diagnosis? Review Topic

. Pectoralis major tendon rupture
. Supraspinatus rupture
. Subscapularis rupture
. Bankart tear
. Humeral avulsion of the inferior glenohumeral ligament

Correct Answer & Explanation

. Pectoralis major tendon rupture

Explanation

The MRI scan shows detachment of the subscapularis from its insertion on the lesser tuberosity. The examination finding is consistent with a positive lift-off test, also indicating a tear of the subscapularis.

Question 612

Topic: Shoulder & Hip Sports

Figure 20 shows the plain radiograph of a 70-year-old woman who has shoulder pain and is unable to reach above chest level as a result of a fall 3 months ago. An MRI scan of the shoulder shows a large rotator cuff tear. Examination reveals atrophy of the infraspinatus muscle, active forward elevation of 40 degrees, active external rotation of 30 degrees, passive forward elevation of 150 degrees, and passive external rotation of 60 degrees. The patient has no external rotation strength against resistance. Treatment should include

. repair of the rotator cuff.
. rehabilitation of the shoulder
. replacement of the humeral head.
. arthroscopic acromioplasty and debridement.
. immobilization is a sling until pain resolves.

Correct Answer & Explanation

. rehabilitation of the shoulder

Explanation

This defines a 70y/o lady who 3 months ago sustained a large, to massive rotator cuff tear, not only by MRI, but by physical exam as well. In any age group or duration from injury, massive rotator cuff tears do poorly with surgical intervention. Now add in 3months duration and 70 yr age and boy doesn't rehabilitation sound good.

Question 613

Topic: Shoulder & Hip Sports
When comparing the addition of a trough at the greater tuberosity to direct repair of cortical bone, simulated rotator cuff repair in animal models has shown what type of change in the strength of the repair?
. 0% increase
. 25% increase
. 50% increase
. 25% decrease
. 50% decrease

Correct Answer & Explanation

. 0% increase

Explanation

DISCUSSION: There was no difference observed in the healing of tendon to bone when comparing healing to cortical bone and to a cancellous trough. REFERENCE: St Pierre P, Olson EJ, Elliott JJ, et al: Tendon healing to cortical bone compared with healing to a cancellous trough. J Bone Joint Surg Am 1995;77:1858-1866.

Question 614

Topic: Shoulder & Hip Sports

A 29-year-old male rugby player presents for further evaluation and management of left shoulder instability. He initially dislocated his left shoulder six years ago while snowboarding. Since that time, he has sustained five dislocations requiring reduction. He has participated in multiple rounds of physical therapy without improvement. His CT scan and 3D reconstruction are pictured in Figures A and B. Which of the following is the most appropriate treatment for this patient? Review Topic

. Open capsular shift
. Remplissage
. Arthroscopic Bankart repair
. Arthroscopic Bankart repair + Remplissage
. Open coracoid transfer

Correct Answer & Explanation

. Open capsular shift

Explanation

This patient has recurrent anterior glenohumeral instability with >20% glenoid bone loss and therefore would benefit most from an open coracoid transfer (Latarjet procedure).Recurrent anterior shoulder instability occurs in 33-67% of patients who sustain an initial traumatic dislocation. Specific risk factors include age < 25 years, male gender, anterior glenoid (Bankart) and/or posterior humeral (Hill-Sachs) osseous defect(s) and participation in contact sports. Surgical management of recurrent instability depends on the presence or absence of glenohumeral bone loss. Patients with < 20% glenoid bone loss can be managed with arthroscopic Bankart repair. An engaging Hill-Sachs lesion, meaning the humeral head defect engages the glenoid rim in abduction (ABD) and external rotation (ER) [see Illustration B], in the setting of minimal glenoid bone loss can be managed with remplissage. Patients with > 20% glenoid bone loss require greater stabilization, mostly commonly in the form of an open coracoid transfer (Latarjet procedure).Burkhart et al. (2000) found arthroscopic Bankart repairs equivalent to open Bankart repairs if no substantial bone defects were present. However, patients with an “inverted pear” glenoid secondary to significant anteroinferior bone loss or an engaging Hill-Sachs lesion of the humerus had a 67% recurrence rate overall and an 89% recurrence rate if they were contact athletes. Therefore, contact athletes with structural bone deficits require open surgery and often necessitate reconstruction with bone-block procedures.Itoi et al. determined that an osseous defect with a width of >/= 21% of the glenoid length was associated with anteroinferior instability in ABD and internal rotation (IR), as well as loss of external rotation following Bankart repair. The authors concluded that while Bankart repair in the setting of a substantial bone loss conferred adequate stability in ABD and ER, it did so at the cost of overtightening the anterior structures which limited ER and did not affect stability in IR when the anterior capsuloligamentous structures are lax.Burkhart et al. (2007) concluded that in the setting of significant glenohumeral bone deficiency, an open Latarjet procedure had only a 4.9% recurrence rate as compared to a 67% recurrence rate following arthroscopic Bankart repair. The Latarjet procedure works to extend the bony glenoid concavity, provide a dynamic sling from the conjoint tendon, preserve the lower third of the subscapularis and repair the capsule.Figures A and B are the axial CT scan and 3D reconstruction en face view of the glenoid demonstrating significant anteroinferior glenoid bone loss of approximately 40%. Illustration A is an algorithm for the management of anterior shoulder instability based on pertinent risk factors and glenohumeral bone loss. Illustration B compares non-engaging and engaging Hill Sachs lesions. Size and depth of the Hill-Sachs lesion as well as glenoid bone deficiency both contribute to risk of engagement. Illustration C depicts a simplistic version of the Latarjet procedure.Incorrect Responses:

Question 615

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 Review Topic

. 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

. repair of the superior labrum.

Explanation

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 source of surgical failure.

Question 616

Topic: Shoulder & Hip Sports

The usual presentation of traumatic subscapularis tears is most often seen after forced Review Topic

. internal rotation.
. external rotation.
. extension.
. abduction.
. forward flexion.

Correct Answer & Explanation

. internal rotation.

Explanation

The typical mechanism of injury is a fall and the patient grasps something to prevent the fall. This maneuver forces the arm into external rotation against resistance.

Question 617

Topic: Shoulder & Hip Sports

03 The sagittal oblique MRI scan shown in Figure 70 reveals a lesion in the shoulder that typically affects what neurologic structure?

. – Axillary nerve
. – Musculocutaneous nerve
. – Long thoracic nerve
. – Suprascapular nerve to the infraspinatus muscle
. – Suprascapular nerve to the supraspinatus muscleback answerQuestion 199.03

Correct Answer & Explanation

. – Axillary nerve

Explanation

Ganglion cysts in the shoulder has been reported in the literature and when they occur in the shoulder typically compress the suprascapular nerve at the spinoglenoid notch primarily affecting the infraspinatus muscle, but depending on their size may also affect the supraspinatus motor brances.The cysts form either because of a lesion of the capsulolabral complex at the superior/posterosuperior glenoid in the shoulder or because of myxoid degeneration of the capsule.back to this question next question

Question 618

Topic: Shoulder & Hip Sports

A 74-year-old woman with rheumatoid arthritis has pain in the shoulder that has failed to respond to nonsurgical management. AP and axillary radiographs are shown in Figures 24a and 24b. Active forward elevation is 120 degrees and external rotation is 30 degrees. At the time of surgery, a 1-cm rotator cuff tear is found, which is repairable. Which of the following treatment options will result in the most predictable pain relief and function? Review Topic

. Total shoulder arthroplasty and rotator cuff repair
. Rotator cuff repair
. Reverse total shoulder arthroplasty
. Interpositional arthroplasty and rotator cuff repair
. Hemiarthroplasty and rotator cuff repair

Correct Answer & Explanation

. Total shoulder arthroplasty and rotator cuff repair

Explanation

Most studies have shown that total shoulder arthroplasties yield better pain relief and improved forward elevation when compared with hemiarthroplasty in patients with rheumatoid arthritis. Patients with repairable rotator cuff tears should undergo repair at the time of surgery because good results have been shown. Reverse arthroplasties are not indicated with rotator cuff tears that are repairable, and interpositional arthroplasties are not indicated for elderly patients.

Question 619

Topic: Shoulder & Hip Sports
Figure 7 shows a sagittal T1-weighted MRI scan. What muscle/tendon is identified by the arrow?
. Infraspinatus
. Teres minor
. Subscapularis
. Long head of triceps
. Latissimus dorsi

Correct Answer & Explanation

. Teres minor

Explanation

The sagittal T1-weighted MRI scan is useful for interpreting the quality of muscle. The arrow is pointing to the teres minor.

Question 620

Topic: Shoulder & Hip Sports
A patient sustains a transection of the posterior cord of the brachial plexus from a knife injury. This injury would affect all of the following muscles EXCEPT?
. Subscapularis
. Latissimus dorsi
. Supraspinatus
. Teres minor
. Brachioradialis

Correct Answer & Explanation

. Supraspinatus

Explanation

The posterior cord of the brachial plexus gives rise to the 1) upper subscapular nerve, 2) lower subscapular nerve, 3) thoracodorsal nerve, 4) axillary nerve, and 5) radial nerve. The upper subscapular nerve innervates the subscapularis. The lower subscapular nerve innervates teres major and also subscapularis. The thoracodorsal nerve innervates latissimus dorsi. The axillary nerve innervates deltoid and teres minor. The radial nerve innervates the triceps, brachioradialis, wrist extensors, and finger extensors. The supraspinatus is innervated by the suprascapular nerve off the upper trunk and therefore would not be affected by an injury to the posterior cord.

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