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 761
Topic: Shoulder & Hip Sports
Figures 34a and 34b show the axial and sagittal MRI scans of a 36-year-old man who reports the insidious onset of pain in the right shoulder. What is the most appropriate description of the acromial morphology?
Correct Answer & Explanation
. Meso os acromiale
Explanation
The MRI scans reveal a meso os acromiale with edema at the site in a skeletally mature patient. Sher JS: Anatomy, biomechanics, and pathophysiology of rotator cuff disease, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, p 23.
Question 762
Topic: Shoulder & Hip Sports
A 51-year-old woman is seen for evaluation of chronic supraspinatus and infraspinatus tendon tears. Three years ago, in an attempted repair the surgeon was unable to repair the supraspinatus and infraspinatus tendon tears. Currently she has a marked amount of pain, reduced range of motion, and weakness. Examination reveals anterosuperior escape. Radiographs show no signs of arthritic changes. You are considering a latissimus dorsi tendon transfer. During the discussion, you mention that
Correct Answer & Explanation
. with her current anterosuperior escape, she is likely to have a poor surgical result.
Explanation
Latissimus dorsi tendon transfer is considered a surgical option for treatment in patients with chronic supraspinatus and infraspinatus tendon tears. Preoperative subscapularis function is necessary for good clinical results. Additionally, men with active elevation to shoulder level and active external rotation to 20 degrees have predictably good results. Women with active shoulder elevation limited to below chest level have poor results from this procedure and should not be considered candidates. Postoperatively they lack pain control, active elevation, and active external rotation. Muscular atrophy in the latissimus dorsi does not occur, and glenohumeral arthritic changes frequently develop postoperatively. Gerber C, Maquieira G, Espinosa N: Latissimus dorsi transfer for the treatment of irreparable rotator cuff tears: Factors affecting outcome. J Bone Joint Surg Am 2006;88:113-120.
Question 763
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
Correct Answer & Explanation
. deficient anterior capsule.
Explanation
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. Abrams JS: Thermal capsulorrhaphy for instability of the shoulder: Concerns and applications of the heat probe. Instr Course Lect 2001;50:29-36.
Question 764
Topic: Shoulder & Hip Sports
A 20-year-old professional baseball pitcher has had a 3-year history of increased aching in his shoulder that is associated with pitching, and he is now seeking a second opinion. Nonsurgical management consisting of rest, anti-inflammatory drugs, ice, heat, and cortisone injections has failed to provide relief. A previous work-up that included radiographs and gadolinium-enhanced MRI arthrography was negative. Results of an arteriogram suggest quadrilateral space syndrome. Assuming that this is the correct diagnosis, what nerve needs to be decompressed?
Correct Answer & Explanation
. Axillary
Explanation
Quadrilateral space syndrome is a rare condition and is the result of compression of the contents of the quadrilateral space. The contents of the quadrilateral space include the posterior circumflex vessels and the axillary nerve. Cahill BR, Palmer RE: Quadrilateral space syndrome. J Hand Surg 1983;8:65-69.
Question 765
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?
Correct Answer & Explanation
. Os acromiale
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. Kurtz CA, Humble BJ, Rodosky MW, et al: Symptomatic os acromiale. J Am Acad Orthop Surg 2006;14:12-19.
Question 766
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?
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. If the humeral head were directly against the glenoid bone, then catastrophic fracture of the glenoid would be the working diagnosis. Hattrup SJ, Cofield RH, Cha SS: Rotator cuff repair after shoulder replacement. J Shoulder Elbow Surg 2006;15:78-83.
Question 767
Topic: Shoulder & Hip Sports
Figure 4a shows the radiograph of a 20-year-old man who has an injury to the right shoulder. Figure 4b shows an arthroscopic view (posterior portal). The arrow points to a
Correct Answer & Explanation
. Hill-Sachs defect.
Explanation
The radiograph shows an anterior dislocation of the shoulder. A frequently encountered sequela of this is a compression fracture of the posterolateral humeral head, commonly referred to as a Hill-Sachs defect. The arthroscopic view of the glenohumeral joint visualizes the posterior aspect of the humeral head. In the image, the area devoid of cartilage to the right is the bare area. The indentation seen to the left is a Hill-Sachs defect. Matsen FA, Thomas SC, Rockwood CA, et al: Glenohumeral instability, in Rockwood CA, Matsen FA (eds): The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 611-754.
Question 768
Topic: Shoulder & Hip Sports
A football lineman who sustained a traumatic injury while blocking during a game now reports that his shoulder is slipping while pass blocking. Examination reveals no apprehension in abduction and external rotation; however, he reports pain with posterior translation of the shoulder. He has full strength in external rotation, internal rotation, and supraspinatus testing. What is the pathology most likely responsible for his symptoms?
Correct Answer & Explanation
. Posterior labral tear
Explanation
Traumatic posterior instability is a common finding in football players, especially in the blocking positions as well as in the defensive linemen and linebackers. A traumatic blow to the outstretched arm results in posterior glenohumeral forces. Labral detachment at the glenoid rim is common. Patients report slipping or pain with posteriorly directed pressure. Rarely do these patients have true dislocations that require reduction; however, recurrent episodes of subluxation or pain are not uncommon. Posterior repair has been shown to be successful in the treatment of traumatic instability. Bottoni CR, Franks BR, Moore JH, et al: Operative stabilization of posterior shoulder instability. Am J Sports Med 2005;33:996-1002. Williams RJ III, Strickland S, Cohen M, et al: Arthroscopic repair for traumatic posterior shoulder instability. Am J Sports Med 2003;31:203-209.
Question 769
Topic: Shoulder & Hip Sports
A 25-year-old carpenter falls on his outstretched arm. What physical finding best correlates with the lesion seen on the MRI scan shown in Figure 3?
Correct Answer & Explanation
. Positive lift-off test
Explanation
The MRI scan shows disruption of the subscapularis muscle. Subscapularis rupture is associated with weakness in internal rotation as shown with a positive lift-off test as described by Gerber and Krushell. The belly press test also has been shown to be a useful clinical test for this problem. Weakness in external rotation and abduction is more consistent with supraspinatus and infraspinatus tears. Deltoid atrophy is associated with an axillary nerve injury. Loss of biceps contour is associated with rupture of the long head of the biceps. Gerber C, Krushell RJ: Isolated rupture of the tendon of the subscapularis muscle: Clinical features in 16 cases. J Bone Joint Surg Br 1991;73:389-394.
Question 770
Topic: Shoulder & Hip Sports
A patient with deficient anteroinferior bone stock undergoes a Latarjet procedure that transfers a portion of the coracoid to the glenoid rim and secures it with two screws. After surgery, the patient reports numbness on the anterolateral forearm. To verify the diagnosis, what muscle should be tested for strength?
Correct Answer & Explanation
. Biceps
Explanation
A Latarjet procedure is similar to a Bristow procedure, but with the Latarjet procedure a larger portion of the coracoid is transferred to the scapular neck at the anteroinferior glenoid. As in a Bristow procedure, if the fragment is pulled or twisted during the dissection or during fixation, the musculocutaneous nerve can be injured. With loss of biceps function, elbow flexion and forearm supination will be weaker. Ho E, Cofield RH, Balm MR, Hattrup SJ, Rowland CM: Neurologic complications of surgery for anterior shoulder instability. J Shoulder Elbow Surg 1999;8:266-270. Boardman ND 3rd, Cofield RH: Neurologic complications of shoulder surgery. Clin Orthop 1999;368:44-53.
Question 771
Topic: Shoulder & Hip Sports
A 22-year-old competitive volleyball player has shoulder pain, and rest and a cortisone injection have failed to provide relief. Examination reveals atrophy along the posterior scapula, but an MRI scan does not reveal a rotator cuff tear or labral cyst. What is the most likely cause for the shoulder weakness?
Correct Answer & Explanation
. Suprascapular nerve injury
Explanation
Repetitive overhead slams and serves may produce a traction injury to the distal branch of the suprascapular nerve. Bankart, biceps, and superior labrum anterior and posterior injuries can occur but usually do not produce visible atrophy. Muscle avulsion is uncommon. Ferretti A, Cerullo G, Russo G: Suprascapular neuropathy in volleyball players. J Bone Joint Surg Am 1987;69:260-263.
Question 772
Topic: Shoulder & Hip Sports
The MRI scan of the shoulder shown in Figure 2 was performed with the arm in abduction and external rotation. The image reveals what condition?
Correct Answer & Explanation
. Contact between the rotator cuff and the posterior-superior labrum
Explanation
Internal impingement of the shoulder is now a well-recognized cause of shoulder pain in the throwing athlete. First described by Walch and associates, it involves contact of the rotator cuff and labrum in the maximally externally rotated and abducted shoulder, such as in the late cocking phase of the throwing motion. Schickendantz and associates have shown this contact to be physiologic in most patients and becoming pathologic with repetitive overhead activity. Schickendantz MS, Ho CP, Keppler L, Shaw BD: MR imaging of the thrower's shoulder: Internal impingement, latissimus dorsi/subscapularis strains, and related injuries. Magn Reson Imaging Clin N Am 1999;7:39-49. 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 773
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
Correct Answer & Explanation
. pectoralis tenotomy and subscapularis tendon lengthening.
Explanation
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. Braun RM, Botte MJ: Treatment of shoulder deformity in acquired spasticity. Clin Orthop 1999;368:54-65.
Question 774
Topic: Shoulder & Hip Sports
A 35-year-old recreational basketball player reports shoulder pain following a sprawl for a rebound. While examination reveals that he can actively elevate the arm with pain, a subacromial injection fails to provide relief. An MRI scan reveals medial subluxation of the long head of the biceps. Which of the following structures most likely has also been injured?
Correct Answer & Explanation
. Subscapularis tendon
Explanation
Subscapularis tears can be associated with disruption of the transverse ligament supporting the biceps. The remaining aspects of the rotator cuff, superior labrum, and capsule can be intact with this injury. Petersson CJ: Spontaneous medial dislocation of the tendon of the long biceps brachii. Clin Orthop 1986;211:224-227.
Question 775
Topic: Shoulder & Hip Sports
A 36-year-old woman has pain and swelling of the anterior arm after undergoing arthroscopic shoulder surgery 8 months ago. At the time of the procedure, extensive debridement and synovectomy of the anterior aspect of the joint was performed to remove scar tissue that had formed after an open rotator cuff repair. Examination reveals a golf ball-sized swelling just lateral to the coracoid. The area is not warm and shows no other signs of infection. An MRI scan is shown in Figure 1. Management should now consist of
Correct Answer & Explanation
. repair of the rotator cuff interval.
Explanation
Deficiency of the rotator cuff interval may be acquired or congenital. In this patient, extensive debridement of the rotator cuff interval capsule at the time of arthroscopy most likely is the cause of the defect seen on the MRI scan. Surgical closure of the defect is the treatment of choice. During the repair, the shoulder should be placed in 30 degrees of external rotation to avoid overtightening. Care should be taken to include the leading edge of both the supraspinatus and subscapularis tendons in the repair because the rotator cuff interval capsular tissue is likely to be of poor quality. Cole BJ, Rodeo SA, O'Brien SJ, et al: The anatomy and histology of the rotator interval capsule of the shoulder. Clin Orthop 2001;390:129-137.
Question 776
Topic: Shoulder & Hip Sports
A 35-year-old woman dislocated her right shoulder in a fall from a step stool several months ago. She now reports several painful recurrences. Examination reveals anterior and inferior apprehension that reproduces her symptoms. An MRI scan is shown in Figure 17. Management should consist of
Correct Answer & Explanation
. open repair of the lateral joint capsule disruption.
Explanation
The MRI findings reveal a disruption of the humeral insertion of the glenohumeral ligaments and joint capsule (humeral avulsion of the glenohumeral ligament). This lesion has been reported to account for an 8% rate of recurrent dislocation in a subset of patients who are typically older than those with the more common lesions of the glenoid labrum (Bankart lesion). Open repairs have been reported to be successful in the prevention of recurrent instability. Since there is no Bankart lesion, open or arthroscopic labral repairs are not indicated. Nonsurgical management is possible if the patient does not want to undergo surgery; however, the recurrence rate is very high. Wolf EM, Cheng JC, Dickson K: Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 1995;11:600-607. Bokor DJ. Conboy VB. Olson C: Anterior instability of the glenohumeral joint with humeral avulsion of the glenohumeral ligament: A review of 41 cases. J Bone Joint Surg Br 1999;81:93-96.
Question 777
Topic: Shoulder & Hip Sports
A 65-year-old woman sustained an axial load on the arm followed by an abduction injury after falling on ice. Treatment in the emergency department consisted of reduction of an anterior dislocation. She now has a positive drop arm sign and a positive lift-off test. An MRI scan is shown in Figure 9. Based on these findings, management should consist of
Correct Answer & Explanation
. repair of the subscapularis tendon and biceps tenodesis.
Explanation
Dislocation of the long head of the biceps tendon is the result of a defect in the region of the rotator cuff interval, coracohumeral ligament-superior glenohumeral ligament pulley, or an associated tear of the medial insertion of the subscapularis tendon. In the case of an intra-articular dislocation of the long head of the biceps tendon associated with a tear of the subscapularis tendon, stabilization of the biceps tendon is difficult in this situation; therefore, biceps release or tenodesis and repair of the subscapularis tendon is the treatment of choice. Eakin CL, Faber KJ, Hawkins RJ, et al: Biceps tendon disorders in athletes. J Am Acad Orthop Surg 1999;7:300-310. Sethi N, Wright R, Yamaguchi K: Disorders of the long head of the biceps tendon. J Shoulder Elbow Surg 1999;8:644-654.
Question 778
Topic: Shoulder & Hip Sports
A 43-year-old bus driver sustains a hyperextension injury to her arm and shoulder 4 months after undergoing an open Bankart repair. Examination reveals increased external rotation, anterior shoulder pain, and internal rotation weakness. Her examination also reveals the findings shown in Figure 44. What is the most likely diagnosis?
Correct Answer & Explanation
. Subscapularis rupture
Explanation
An isolated tear of the subscapularis tendon has been noted as early as 1835 by Smith. In Gerber and associates' 1991 report of 16 men with an average age of 51 years, isolated subscapularis tendon rupture was often caused by a violent hyperextension injury. All patients reported pain anteriorly along with night pain. They also noted pain and weakness of the arm. The lift-off test is performed by having the patient lift the palm of the hand away from the small of the back. The patient must have sufficient internal rotation to allow this test to be performed. A subscapularis rupture is likely if the patient cannot perform the lift-off test.
Question 779
Topic: Shoulder & Hip Sports
A 58-year-old woman with a history of severe asthma and long-term prednisone use reports a progression of chronic shoulder pain for the past 6 months. Radiographs and MRI scans are shown in Figures 30a through 30d. What is the most likely diagnosis?
Correct Answer & Explanation
. Osteonecrosis of the humeral head
Explanation
The patient has osteonecrosis of the humeral head. The radiographs show increased density in the superior subchondral region of the humeral head. The MRI scans reveal a central collapse of the humeral head. The patient's history of severe asthma and long-term prednisone use predisposes her to this condition. The MRI scans show no evidence of a full- or partial-thickness rotator cuff tear. Without a history of fevers, chills, or other systemic signs or symptoms, there is no indication of septic arthritis. The radiographs do not reveal periarticular erosions, commonly seen in rheumatoid arthritis. Matsen FA III, Rockwood CA Jr, Wirth MA, et al: Glenohumeral arthritis and its management, in Rockwood CA Jr, Matsen FA III (eds): Rockwood and Matsen The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 871-874.
Question 780
Topic: Shoulder & Hip Sports
A 72-year-old woman who fell on her right shoulder while using a treadmill is now unable to elevate her right arm. An MRI scan is shown in Figure 7. What is the most likely diagnosis?
Correct Answer & Explanation
. Extension of a chronic large rotator cuff tear
Explanation
The MRI scan reveals a large chronic rotator cuff tear with retraction and fatty infiltration atrophy of the supraspinatus and infraspinatus tendons. This tear is responsible for the patient's severe weakness and inability to elevate the arm.
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