Menu

Shoulder & Hip Sports MCQs

Practice Set 40 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 781

Topic: Shoulder & Hip Sports

A 67-year-old woman is seen in the emergency department after falling at home. Radiographs before and after treatment are shown in Figures 49a and 49b, respectively. Which of the following best explains the 8-week postinjury clinical findings seen in Figure 49c?

. Axillary nerve palsy
. Spinal accessory nerve palsy
. Deltoid avulsion
. Rotator cuff tear
. Unreduced posterior glenohumeral dislocation

Correct Answer & Explanation

. Rotator cuff tear

Explanation

Patients older than age 40 years at the time of initial anterior dislocation have low rates of redislocation; however, 15% of these patients experience a rotator cuff tear. Moreover, there is a dramatic increase (up to 40%) in the incidence of rotator cuff tears in patients older than age 60 years. Axillary nerve injury may occur but is less common than rotator cuff tear. Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 273-284.

Question 782

Topic: Shoulder & Hip Sports

A 45-year-old recreational tennis player underwent arthroscopic decompression and mini-open repair of a small supraspinatus tendon tear 3 weeks ago after nonsurgical management failed to provide relief. He now has pain, swelling about the wound, erythema, and purulent drainage. The patient is returned to the operating room for irrigation, debridement, and cultures. What is the most common organism causing this infection?

Upper Extremity 2005 Practice Questions: Set 1 (Solved) - Figure 2

. Staphylococcus epidermidis
. Methicillin-resistant Staphylococcus aureus
. Pseudomonas aeruginosa
. Propionibacterium acnes
. Clostridium tetani

Correct Answer & Explanation

. Propionibacterium acnes

Explanation

In a large series of mini-open rotator cuff repairs, an infection rate of at least 2% was found, with the majority of the infections caused by Propionibacterium acnes. To prevent this complication, the shoulder should be re-prepped before the mini-open incision is made to prevent bacterial contamination from the arthroscopic procedure. Herrera MF, Bauer G, Reynolds F, et al: Infection after mini-open rotator cuff repair. J Shoulder Elbow Surg 2002;11:605-608.

Question 783

Topic: Shoulder & Hip Sports

A 64-year-old man who underwent total shoulder arthroplasty 4 weeks ago is making satisfactory progress in physical therapy, but his therapist notes limitations in external rotation to neutral. A stretching program is started, and the patient suddenly gains 90 degrees of external rotation but now reports increased pain and weakness. What is the best course of action?

. Early surgical exploration and repair of the torn subscapularis tendon
. Observation and reassurance that the pain will resolve
. A slow progressive resistance program to restore strength
. CT to assess for component malrotation
. Electromyography to evaluate for possible nerve injury

Correct Answer & Explanation

. Early surgical exploration and repair of the torn subscapularis tendon

Explanation

Nearly all approaches to shoulder arthroplasty require detachment of the subscapularis tendon from the humerus and subsequent repair. Healing of this tenotomy is one of the limiting factors in postoperative recovery. Failure of the tenotomy repair must be recognized and treated early with repeat repair or pectoralis muscle transfer for optimal results. Failure of the subscapularis is diagnosed clinically as excessive external rotation and weakness, especially in the lift-off or belly press position. Muscle testing can be difficult in the postoperative period and may not be possible to assess in those positions. Although MRI might be useful to confirm the diagnosis, studies may be limited by artifact. CT or electromyography would not be diagnostic. Wirth MA, Rockwood CA Jr: Complications of total shoulder-replacement arthroplasty. J Bone Joint Surg Am 1996;78:603-616.

Question 784

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

Upper Extremity 2008 Practice Questions: Set 1 (Solved) - Figure 10

. 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

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. 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.

Question 785

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?

Anatomy 2008 Practice Questions: Set 3 (Solved) - Figure 22

. 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

. Anterior labroligamentous periosteal sleeve avulsion (ALPSA 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. Neviaser TJ: The anterior labroligamentous periosteal sleeve avulsion lesion: A cause of anterior instability of the shoulder. Arthroscopy 1993;9:17-21.

Question 786

Topic: Shoulder & Hip Sports

A baseball pitcher has intractable posterior and superior shoulder pain. The arthroscopic view seen in Figure 25 shows no Bankart or Hill-Sachs lesion and a negative drive-through sign. There are no signs of ligamentous laxity, but active compression and anterior slide tests are positive. Treatment should consist of

Upper Extremity 2005 Practice Questions: Set 3 (Solved) - Figure 5

. open fixation of the SLAP lesion with a screw that can be removed later.
. arthroscopic repair of the SLAP lesion with suture anchors.
. arthroscopic repair of the SLAP lesion with suture anchors with a thermal capsular shift.
. arthroscopic repair of the SLAP lesion with suture anchors and a rotator cuff interval closure.
. arthroscopic repair of the SLAP lesion with suture anchors and an arthroscopic capsular placation.

Correct Answer & Explanation

. arthroscopic repair of the SLAP lesion with suture anchors.

Explanation

According to Morgan and associates, a type II SLAP lesion can create or is associated with a superior instability pattern. They suggest that this can exist without a co-existing anteroinferior instability pattern. They reported that repair of the SLAP lesion alone resulted in satisfactory outcomes in 90% of patients and a return to throwing in more than 90% of pitchers. The arthroscopic findings in this patient do not support a diagnosis of anteroinferior laxity or instability; therefore, thermal capsular shift or capsular placation is not necessary. Morgan CD, Burkhart SS, Palmeri M, et al: Type II SLAP lesions: Three subtypes and their relationships to superior instability and rotator cuff tears. Arthroscopy 1998;14:553-565. Mileski RA, Snyder RJ: Superior labral lesions in the shoulder: Pathoanatomy and surgical management. J Am Acad Orthop Surg 1998;6:121-131.

Question 787

Topic: Shoulder & Hip Sports

A 54-year-old man undergoes total shoulder arthroplasty for osteoarthritis. Despite compliance with an early passive range-of-motion exercise program, he does not regain more than 90 degrees of elevation, 10 degrees of external rotation, and has internal rotation to the fifth lumbar vertebra. At 6 months, his motion fails to improve. Radiographs are shown in Figures 18a and 18b. What is the best course of action?

. Continue with a more aggressive passive range-of-motion exercise program.
. Perform an open release.
. Revise the humeral component and increase retroversion.
. Revise the humeral component alone after osteotomizing more of the humeral neck and seating the component lower.
. Remove the glenoid component to decrease tension in the rotator cuff.

Correct Answer & Explanation

. Perform an open release.

Explanation

The patient has a global loss of motion that has failed to improve with 6 months of nonsurgical treatment; because he has reached a plateau, further nonsurgical management will likely be ineffective. Revision in the form of an open release is indicated to lyse intra- and extra-articular adhesions; subscapularis lengthening may be done concurrently as needed. Revising to a smaller head can be considered if adequate motion is not achieved. The radiographs reveal an adequate neck cut with appropriate seating of the component. Removing the glenoid component will decrease capsular tension but will probably increase pain because of the lack of glenoid resurfacing. Increasing humeral retroversion will not improve motion. Cuomo F, Checroun A: Avoiding pitfalls and complication in total shoulder arthroplasty. Orthop Clin North Am 1998;29:507-518.

Question 788

Topic: Shoulder & Hip Sports

A 68-year-old woman has been progressing slowly after undergoing humeral head replacement for a four-part fracture 3 months ago. She has not regained active elevation, she feels an audible clunk on attempting elevation, and she reports pain and weakness. She used a sling for 2 weeks in the immediate postoperative period. Radiographs are shown in Figure 37a through 37c. Management should consist of

. tuberosity and rotator cuff repair with bone graft.
. revision arthroplasty leaving the prosthesis proud to increase humeral length and muscle tension.
. revision total shoulder arthroplasty to neutralize eccentric glenoid wear.
. revision of the humeral head replacement alone with increased retroversion.
. additional therapy to include internal and external rotation strengthening of the rotator cuff.

Correct Answer & Explanation

. tuberosity and rotator cuff repair with bone graft.

Explanation

Immediate repair of the tuberosity and rotator cuff is recommended on identifying the avulsion or nonunion. Revising the humeral component to increase tension and length will overtighten the cuff and increase the chance of tuberosity pull-off. The glenoid is uninvolved and should not be replaced. Attempts to strengthen the rotator cuff will be unsuccessful because the insertions are no longer attached to the humerus when the tuberosities avulse. Brown TD, Bigliani LU: Complications with humeral head replacement. Orthop Clin North Am 2000;31:77-90.

Question 789

Topic: Shoulder & Hip Sports

A patient has right shoulder pain. Figure 1a shows a gadolinium-enhanced transverse MRI scan at the level of the coracoid. Figure 1b shows an arthroscopic view of the anterior structures from a posterior portal. These images reveal which of the following findings?

. Normal anatomic variant (Buford complex)
. Glenoid labral tear (superior labrum anterior and posterior)
. Bankart lesion
. Avulsion of the biceps tendon
. Subscapularis tendinitis

Correct Answer & Explanation

. Normal anatomic variant (Buford complex)

Explanation

The area shown in the arthroscopic view and MRI scan is referred to as a Buford complex and represents a normal labral variant. It consists of a thickened, cord-like middle glenohumeral ligament, a superior labral attachment of the middle glenohumeral ligament just anterior to the biceps tendon, and absence of the anterosuperior labrum. This combination of findings can be confusing and may simulate labral pathology. Mistaken repair of the lesion back to the glenoid rim can result in significant loss of external rotation. A Bankart lesion would be located at the inferior anterior glenoid rim. The subscapularis is seen anterior to the labrum. Normal variations that occur in the anterosuperior labrum can simulate pathology. Gusmer PB, Potter HG, Schatz JA, et al: Labral injuries: Accuracy of detection with unenhanced MR imaging of the shoulder. Radiology 1996;200:519-524. Griffin LY (ed): Orthopaedic Knowledge Update: Sports Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 47-63.

Question 790

Topic: Shoulder & Hip Sports

During shoulder motion with the elbow controlled in a brace, electromyographic studies of the supraspinatus show significant activity with all range-of-motion testing. Concurrent electromyographic studies of the long head of the biceps will most likely show

Upper Extremity Board Review 2005: High-Yield MCQs (Set 2) - Figure 13

. minimal activity.
. moderate activity compared to the supraspinatus.
. significant activity with a supraspinatus tear.
. significant activity with an intact supraspinatus.
. significant activity with both intact and torn rotator cuffs.

Correct Answer & Explanation

. minimal activity.

Explanation

During electromyographic studies, the long head of the biceps has been shown to have little activity throughout a wide range of shoulder motion as long as the elbow is immobilized. The supraspinatus is active throughout the range of shoulder motion. Rotator cuff tears do not influence biceps activity as long as the elbow is controlled. Yamaguchi K, Riew KD, Galutz LM, et al: Biceps activity during shoulder motion: An electromyographic analysis. Clin Orthop 1997;336:122-129.

Question 791

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

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. Moeckel BH, Altchek DW, Warren RF, Wickiewicz TL, Dines DM: Instability of the shoulder after arthroplasty. J Bone Joint Surg Am 1993;75:492-497.

Question 792

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

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. Gerber C, Krushell RJ: Isolated ruptures of the tendon of the subscapularis muscle: Clinical fractures in 16 cases. J Bone Joint Surg Br 1991;73:389-394.

Question 793

Topic: Shoulder & Hip Sports

A 19-year-old wrestler has numbness along the radial aspect of the forearm after undergoing an open Bankart repair through an anterior deltopectoral approach. Motor weakness would be expected along with what other finding?

Anatomy 2005 Practice Questions: Set 1 (Solved) - Figure 9

. Diminished elbow flexion and supination strength
. Reduced grip strength
. Weakness in shoulder abduction
. Weakness in flexion of the distal interphalangeal joint in the index finger
. Weakness of the abductor digiti minimi

Correct Answer & Explanation

. Diminished elbow flexion and supination strength

Explanation

The musculocutaneous nerve may be injured by retracting the conjoined tendon medially. This nerve enters the coracobrachialis 5 cm distal to its origin. Its sensory distribution is the radial forearm, and its motor supply is to the biceps and brachialis. Bach BR, O'Brien SJ, Warren RF, et al: An unusual neurologic complication of the Bristow procedure. J Bone Joint Surg Am 1988;70:458-460.

Question 794

Topic: Shoulder & Hip Sports

A 25-year-old man injures his shoulder while skiing. Examination reveals increased passive external rotation, pain in the cocked position, and a positive lift-off test. What is the most likely diagnosis?

Sports Medicine Board Review 2001: High-Yield MCQs (Set 2) - Figure 19

. Ruptured biceps tendon
. Subscapularis tear
. Anterior subluxation
. Internal impingement syndrome
. Locked posterior dislocation

Correct Answer & Explanation

. Subscapularis tear

Explanation

A positive lift-off test and increased passive external rotation are diagnostic of a subscapularis tear or detachment. Although a similar injury could produce anterior instability, this will test the integrity of the subscapularis. A locked dislocation has limited passive movement. A ruptured biceps tendon will most likely produce ecchymosis and findings similar to supraspinatus trauma. Internal impingement is not associated with subscapularis weakness. 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 795

Topic: Shoulder & Hip Sports

Figures 49a and 49b show MRI scans of the shoulder. What is the most likely diagnosis?

. Rotator cuff tear
. Normal anatomic variant
. Stage II impingement
. Bankart lesion
. Acromioclavicular grade II sprain

Correct Answer & Explanation

. Rotator cuff tear

Explanation

The supraspinatus tendon shows clear detachment and retraction from its greater tuberosity attachment by the absence of the normal dark subacromial signal extending to the attachment on the greater tuberosity. There is no anterior inferior glenoid labral detachment that usually is seen in a Bankart lesion. The acromioclavicular joint shows no evidence of separation. The humeral head is migrated cranially, indicating a chronic rotator cuff tear. Iannotti JP, Zlatkin MB, Esterhai JL, Kressel HY, Dalinka MK, Spindler KP: Magnetic resonance imaging of the shoulder: Sensitivity, specificity, and predictive value. J Bone Joint Surg Am 1991;73:17-29. Seeger LL, Gold RH, Bassett LW, Ellman H: Shoulder impingement syndrome: MR findings in 53 shoulders. Am J Roentgenol 1988;150:343-347.

Question 796

Topic: Shoulder & Hip Sports

Figures 39a and 39b show the MRI scans of a 25-year-old man with right shoulder pain. Figure 39c shows the arthroscopic view from a posterior portal in the beach chair position. What is the most likely diagnosis?

. Bankart lesion
. Superior labral tear
. Partial articular surface supraspinatus tear
. Partial bursal surface supraspinatus tear
. Full-thickness supraspinatus tear

Correct Answer & Explanation

. Partial articular surface supraspinatus tear

Explanation

The MRI scans show coronal oblique and sagittal oblique views of a partial articular surface supraspinatus tear or tendon avulsion (PASTA lesion). The arthroscopic view is a posterior portal of the glenohumeral joint viewing the articular surface of the supraspinatus. These tears are a common source of shoulder pain and are often amenable to transtendon arthroscopic repair without detachment of the intact bursal surface. Sanders TG, Miller MD: A systematic approach to magnetic resonance imaging interpretation of sports medicine injuries of the shoulder. Am J Sports Med 2005;33:1088-1105. McConville OR, Iannotti JP: Partial-thickness tears of the rotator cuff: Evaluation and management. J Am Acad Orthop Surg 1999;7:32-43.

Question 797

Topic: Shoulder & Hip Sports

Figure 47 shows a transverse MRI scan of a patient's left shoulder. The findings reveal which of the following abnormalities?

Anatomy Board Review 2002: High-Yield MCQs (Set 4) - Figure 9

. Subscapularis tear
. Coracoid fracture
. Osteonecrosis of the humeral head
. Posterior labral tear
. Hill-Sachs lesion

Correct Answer & Explanation

. Hill-Sachs lesion

Explanation

The MRI scan shows a defect in the posterior aspect of the humeral head, commonly referred to as a Hill-Sachs lesion. This is an impaction fracture of the humeral head that occurs during anterior shoulder dislocation. The abnormality on this image is an irregularity of the posterior humeral head; the humeral head otherwise has a homogenous appearance. The coracoid, subscapularis, and posterior labrum are normal. Griffin LY (ed): Orthopaedic Knowledge Update: Sports Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 47-63.

Question 798

Topic: Shoulder & Hip Sports

A 22-year-old female collegiate javelin thrower has shoulder pain. She notes that her pain is primarily located in the posterior aspect of her shoulder, is exacerbated with throwing, and she experiences maximal tenderness in the extreme cocking phase of the throwing cycle. On examination, she reports deep posterior shoulder pain when the arm is abducted 90 degrees and maximally externally rotated to 110 degrees. This reproduces her symptoms precisely. Shoulder radiographs are normal. What is the most likely diagnosis?

. Anterior shoulder instability
. Early adhesive capsulitis
. Internal impingement
. Subacromial impingement
. Full-thickness rotator cuff tear

Correct Answer & Explanation

. Internal impingement

Explanation

The patient has internal impingement. Internal impingement is commonly seen in overhead throwing athletes. When positioned in the extreme cocking phase of the throwing cycle, the posterior glenoid impacts the articular surface of the infraspinatus and posterior fibers of the supraspinatus tendon. This impact can cause partial-thickness rotator cuff tearing and posterosuperior labral lesions. She has no evidence of anterior shoulder instability, and her range of motion is excellent which rules out adhesive capsulitis. Subacromial impingement is identified with anterolateral shoulder pain with internal rotation in the abducted position. A full-thickness rotator cuff tear in a 22-year-old individual would require significant trauma and would likely result in pain at rest and with lifting. Meister K, Buckley B, Batts J: The posterior impingement sign: Diagnosis of rotator cuff and posterior labral tears secondary to internal impingement in overhand athletes. Am J Orthop 2004;33:412-415.

Question 799

Topic: Shoulder & Hip Sports
A 72-year-old man injured his right shoulder after tripping over a chair leg. Radiographs obtained in the emergency department reveal an isolated anterior dislocation. After successful closed reduction, the patient has recurrent anterior instability and is unable to elevate the arm. What is the most likely cause of the recurrent instability?
. Infection of the anterior glenoid labral detachment
. Anterior glenoid fracture
. Axillary nerve palsy
. Occult surgical neck fracture
. Rotator cuff tear

Correct Answer & Explanation

. Rotator cuff tear

Explanation

A rotator cuff tear is the most common cause of recurrent instability following a first-time dislocation in patients older than age 40 years. Dislocations occur through a posterior mechanism rather than by an isolated labral avulsion or a Bankart lesion as seen in younger patients.

Question 800

Topic: Shoulder & Hip Sports

A 62-year-old man with a long history of right shoulder pain and weakness is scheduled to undergo hemiarthroplasty. Based on the radiographs shown in Figures 6a through 6c, what preoperative factor will most affect postoperative functional outcome?

. Humeral head erosion
. Glenoid erosion
. Rotator cuff integrity
. Status of the coracoacromial ligament
. Acromioclavicular arthritis

Correct Answer & Explanation

. Rotator cuff integrity

Explanation

The radiographs reveal osteoarthritis and proximal humeral head migration. Integrity of the rotator cuff must be questioned based on these radiographic changes. The status of the rotator cuff is the most influential factor affecting postoperative function in shoulder hemiarthroplasty. The coracoacromial ligament provides a barrier to humeral head proximal migration in the face of a rotator cuff tear. The radiographs do not indicate significant humeral head or glenoid erosion. Acromioclavicular arthritis is often asymptomatic. Iannotti JP, Norris TR: Influence of preoperative factors on outcome of shoulder arthroplasty for glenohumeral osteoarthritis. J Bone Joint Surg Am 2003;85:251-258.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page