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Question 1561

Topic: Shoulder & Hip Sports

A 26-year-old professional volleyball player complains of vague posterior shoulder pain and progressive weakness. Physical examination demonstrates isolated weakness in external rotation with the arm at the side, but normal abduction strength. There is visible atrophy of the infraspinatus fossa. Where is the most likely location of nerve compression?

. Suprascapular notch
. Spinoglenoid notch
. Quadrilateral space
. Triangular interval
. Cubital tunnel

Correct Answer & Explanation

. Suprascapular notch


Explanation

Isolated atrophy and weakness of the infraspinatus with preserved supraspinatus function (normal abduction) indicates compression of the suprascapular nerve at the spinoglenoid notch. This is often caused by a paralabral cyst associated with a posterior or SLAP labral tear in overhead athletes.

Question 1562

Topic: Shoulder & Hip Sports

A 42-year-old male is brought to the emergency department after a first-time seizure. He holds his right arm locked in internal rotation. Radiographs reveal a posterior shoulder dislocation with an anteromedial humeral head impaction fracture (reverse Hill-Sachs lesion). A subsequent CT scan shows the defect involves 35% of the articular surface. Which of the following is the most appropriate surgical treatment?

. Closed reduction and sling immobilization for 4 weeks
. Arthroscopic posterior Bankart repair
. Transfer of the lesser tuberosity into the defect
. Total shoulder arthroplasty
. Anterior coracoid transfer (Latarjet procedure)

Correct Answer & Explanation

. Closed reduction and sling immobilization for 4 weeks


Explanation

Posterior shoulder dislocations following seizures frequently result in a reverse Hill-Sachs lesion. Defects involving 20% to 40% of the articular surface are highly susceptible to engagement and are best treated with a modified McLaughlin procedure (lesser tuberosity transfer) to restore stability.

Question 1563

Topic: Shoulder & Hip Sports

A 22-year-old collegiate rugby player has recurrent anterior shoulder instability. CT scan indicates 25% anterior glenoid bone loss. Which of the following is the most appropriate surgical intervention?

. Arthroscopic Bankart repair
. Open Bankart repair
. Latarjet procedure
. Arthroscopic capsular plication
. Remplissage procedure

Correct Answer & Explanation

. Arthroscopic Bankart repair


Explanation

Glenoid bone loss exceeding 20-25% in a collision athlete is an indication for a bony augmentation procedure like the Latarjet. Soft tissue repairs alone in this setting have an unacceptably high failure rate.

Question 1564

Topic: Shoulder & Hip Sports

A 35-year-old male presents with isolated weakness in external rotation of the shoulder following a severe traction injury. Atrophy of the infraspinatus is noted, but the supraspinatus is clinically and radiographically normal. Where is the most likely site of nerve compression or injury?

. Suprascapular notch
. Spinoglenoid notch
. Quadrilateral space
. Triangular interval
. Spiral groove

Correct Answer & Explanation

. Suprascapular notch


Explanation

Compression of the suprascapular nerve at the spinoglenoid notch affects only the infraspinatus muscle. Compression more proximally at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 1565

Topic: Shoulder & Hip Sports

A 40-year-old man presents with persistent shoulder pain and inability to actively lift his hand off his abdomen (positive belly-press test). MRI demonstrates a complete, retracted subscapularis tear with Goutallier stage 4 fatty infiltration. What is the most appropriate tendon transfer for this patient?

. Latissimus dorsi transfer
. Pectoralis major transfer
. Lower trapezius transfer
. Teres major transfer
. Split pectoralis minor transfer

Correct Answer & Explanation

. Latissimus dorsi transfer


Explanation

Pectoralis major transfer is the standard procedure for an irreparable subscapularis tear to restore anterior stability and internal rotation function. Latissimus dorsi and lower trapezius transfers are typically used for posterosuperior cuff defects.

Question 1566

Topic: Shoulder & Hip Sports

A 65-year-old patient presents with an acute anterior shoulder dislocation after a fall. The joint is successfully reduced. Two weeks later, the patient continues to complain of profound weakness in shoulder abduction and external rotation despite normal radiographs. What is the most likely diagnosis?

. Axillary nerve palsy
. Recurrent anterior dislocation
. Massive rotator cuff tear
. Brachial plexus neuropraxia
. Adhesive capsulitis

Correct Answer & Explanation

. Axillary nerve palsy


Explanation

In patients older than 40 to 60 years, anterior shoulder dislocation is highly associated with an acute rotator cuff tear. Persistent weakness post-reduction in this age group warrants an MRI to evaluate the rotator cuff.

Question 1567

Topic: Shoulder & Hip Sports

A 30-year-old right-hand-dominant male presents with recurrent anterior shoulder instability. An MRI shows an engaging Hill-Sachs lesion without critical glenoid bone loss. Which of the following procedures specifically addresses the engaging nature of this lesion?

. Arthroscopic Bankart repair
. Arthroscopic SLAP repair
. Remplissage procedure
. Coracoid transfer (Latarjet)
. Inferior capsular shift

Correct Answer & Explanation

. Arthroscopic Bankart repair


Explanation

The remplissage procedure involves tenodesis of the infraspinatus and posterior capsule into the Hill-Sachs defect. This converts an intra-articular defect into an extra-articular one, preventing it from engaging the anterior glenoid rim.

Question 1568

Topic: Shoulder & Hip Sports

A 22-year-old competitive rugby player presents with recurrent anterior shoulder instability. Advanced imaging reveals 25% anterior glenoid bone loss and an engaging Hill-Sachs lesion. Which of the following surgical procedures is the most appropriate management to minimize the risk of recurrence?

. Arthroscopic Bankart repair alone
. Arthroscopic Bankart repair with Remplissage
. Open Latarjet procedure
. Open capsular shift
. Arthroscopic superior capsular reconstruction

Correct Answer & Explanation

. Arthroscopic Bankart repair alone


Explanation

For recurrent anterior shoulder instability with critical glenoid bone loss (typically >20%), the Latarjet procedure (coracoid transfer) is the gold standard. It prevents recurrence via a triple effect: a bony block, the sling effect of the conjoined tendon, and capsular repair.

Question 1569

Topic: Shoulder & Hip Sports

A 45-year-old heavy laborer presents with profound external rotation weakness and a massive, irreparable posterosuperior rotator cuff tear. Imaging confirms an intact subscapularis and no evidence of glenohumeral osteoarthritis. Which of the following tendon transfers is most appropriate for this patient?

. Pectoralis major transfer
. Latissimus dorsi transfer
. Upper trapezius transfer
. Serratus anterior transfer
. Pectoralis minor transfer

Correct Answer & Explanation

. Pectoralis major transfer


Explanation

Latissimus dorsi (or lower trapezius) tendon transfers are indicated for young, active patients with irreparable posterosuperior (supraspinatus/infraspinatus) rotator cuff tears and no arthritis. A pectoralis major transfer is indicated for an irreparable subscapularis tear.

Question 1570

Topic: Shoulder & Hip Sports

A 35-year-old male presents with his arm locked in internal rotation following a generalized seizure. A CT scan confirms a posterior shoulder dislocation with an anteromedial humeral head defect (reverse Hill-Sachs lesion) involving 30% of the articular surface. What is the most appropriate management?

. Closed reduction and immobilization in internal rotation
. Arthroscopic posterior labral repair
. Modified McLaughlin procedure
. Latarjet procedure
. Humeral head resurfacing arthroplasty

Correct Answer & Explanation

. Closed reduction and immobilization in internal rotation


Explanation

For locked posterior shoulder dislocations with a reverse Hill-Sachs lesion involving 20-40% of the articular surface, a modified McLaughlin procedure (transfer of the lesser tuberosity/subscapularis into the defect) is indicated to prevent recurrent instability.

Question 1571

Topic: Shoulder & Hip Sports

A 20-year-old male with recurrent anterior shoulder dislocations is found to have 10% glenoid bone loss and a deep, engaging Hill-Sachs lesion on dynamic arthroscopy. Which of the following is the most appropriate arthroscopic management?

. Bankart repair alone
. Bankart repair combined with a Remplissage procedure
. Arthroscopic Latarjet
. Posterior capsular shift
. Rotator interval closure alone

Correct Answer & Explanation

. Bankart repair alone


Explanation

An engaging Hill-Sachs lesion in the setting of subcritical glenoid bone loss (<20%) is best managed with an arthroscopic Bankart repair combined with a Remplissage (infraspinatus tenodesis and posterior capsulodesis into the defect). This prevents the lesion from engaging the anterior glenoid rim.

Question 1572

Topic: Shoulder & Hip Sports

A 30-year-old elite volleyball player presents with vague posterior shoulder pain. MRI reveals a large paralabral cyst in the spinoglenoid notch. Which of the following physical examination findings is most specific to this anatomic level of nerve compression?

. Weakness in both abduction and external rotation
. Weakness in external rotation with preserved abduction strength
. Positive belly-press test
. Positive lift-off test
. Positive O'Brien test

Correct Answer & Explanation

. Weakness in both abduction and external rotation


Explanation

A paralabral cyst in the spinoglenoid notch compresses the suprascapular nerve after it has already innervated the supraspinatus muscle. This leads to isolated denervation of the infraspinatus, presenting clinically as isolated external rotation weakness with preserved abduction strength.

Question 1573

Topic: Shoulder & Hip Sports

A 22-year-old collegiate rugby player presents with his fourth anterior shoulder dislocation this season. A 3D CT scan of the shoulder reveals 26% anterior glenoid bone loss. Which of the following is the most appropriate surgical management to minimize his risk of recurrent instability?

. Arthroscopic Bankart repair alone
. Latarjet procedure
. Arthroscopic remplissage alone
. Open Bankart repair with capsular shift
. Thermal capsulorrhaphy

Correct Answer & Explanation

. Arthroscopic Bankart repair alone


Explanation

Anterior glenoid bone loss exceeding 20-25% is a critical threshold where isolated soft-tissue stabilization (Bankart repair) carries a high failure rate. The Latarjet procedure (coracoid transfer) restores the bony arc and provides a sling effect, making it the treatment of choice.

Question 1574

Topic: Shoulder & Hip Sports

A 35-year-old man presents to the emergency department with a locked posterior shoulder dislocation following a seizure. Following closed reduction, a CT scan reveals an anteromedial humeral head impaction fracture (reverse Hill-Sachs lesion) involving 30% of the articular surface. Which of the following is the most appropriate surgical treatment?

. Arthroscopic posterior capsular shift
. Transfer of the lesser tuberosity into the defect (Modified McLaughlin)
. Osteochondral allograft reconstruction
. Hemiarthroplasty
. Latarjet procedure

Correct Answer & Explanation

. Arthroscopic posterior capsular shift


Explanation

For a reverse Hill-Sachs lesion involving 20-40% of the articular surface, transferring the subscapularis tendon or lesser tuberosity into the defect (McLaughlin or modified McLaughlin procedure) stabilizes the joint and prevents recurrent engagement.

Question 1575

Topic: Shoulder & Hip Sports

A 55-year-old woman is diagnosed with a massive, chronically retracted rotator cuff tear involving the supraspinatus and infraspinatus. She demonstrates profound weakness in external rotation. Electromyography (EMG) reveals denervation of the infraspinatus. What is the most likely mechanism of nerve injury in this setting?

. Compression by an unrecognized paralabral cyst
. Direct mechanical trauma from a prior corticosteroid injection
. Traction neuropathy due to medial retraction of the torn tendon
. Entrapment at the quadrilateral space
. Hypertrophy of the superior transverse scapular ligament

Correct Answer & Explanation

. Compression by an unrecognized paralabral cyst


Explanation

Massive, medially retracted tears of the supraspinatus and infraspinatus can tether the suprascapular nerve. As the tendon retracts, it exerts traction on the nerve, leading to secondary neuropathy.

Question 1576

Topic: Shoulder & Hip Sports

A 19-year-old female gymnast complains of bilateral shoulder pain and a sensation of the shoulders "sliding out of joint." Physical exam demonstrates a positive sulcus sign bilaterally that persists in external rotation, positive apprehension tests, and generalized ligamentous laxity. What is the most appropriate initial management?

. Arthroscopic anterior Bankart repair
. Open inferior capsular shift
. Prolonged immobilization in internal rotation
. Physical therapy focusing on rotator cuff strengthening and scapular stabilization
. Thermal capsulorrhaphy

Correct Answer & Explanation

. Arthroscopic anterior Bankart repair


Explanation

This patient has multidirectional instability (MDI). The gold standard initial management for MDI is an extended course of physical therapy focused on strengthening the dynamic stabilizers (rotator cuff and periscapular muscles).

Question 1577

Topic: Shoulder & Hip Sports

A 52-year-old construction worker complains of deep anterior shoulder pain, particularly when using a hammer. Examination reveals a positive O'Brien's active compression test and tenderness in the bicipital groove. MRI arthrogram demonstrates an isolated Type II SLAP tear. Nonoperative management has failed. What is the preferred surgical intervention?

. Arthroscopic SLAP repair with suture anchors
. Biceps tenodesis
. Biceps tenotomy
. Coracoid decompression
. Arthroscopic superior capsular release

Correct Answer & Explanation

. Arthroscopic SLAP repair with suture anchors


Explanation

In patients older than 40-50 years, biceps tenodesis is preferred over SLAP repair for Type II SLAP lesions. SLAP repairs in this older demographic have higher rates of persistent pain, stiffness, and clinical failure.

Question 1578

Topic: Shoulder & Hip Sports

Following a traumatic anterior shoulder dislocation, a 45-year-old man reports persistent anterior shoulder pain and significant weakness when trying to tuck his shirt into his pants behind his back. Which of the following physical examination tests is most sensitive and specific for evaluating the suspected torn structure?

. Jobe's empty can test
. Hornblower's sign
. Bear hug test
. Neer impingement sign
. Speed's test

Correct Answer & Explanation

. Jobe's empty can test


Explanation

The patient's mechanism and inability to perform internal rotation tasks (tucking in a shirt) suggest a subscapularis tear. The bear hug, belly-press, and lift-off tests are specific maneuvers used to evaluate subscapularis integrity.

Question 1579

Topic: Shoulder & Hip Sports

A 25-year-old recreational athlete presents with recurrent anterior shoulder instability. A 3D CT scan shows 12% anterior glenoid bone loss and a large, engaging Hill-Sachs lesion. Which of the following surgical procedures is most appropriate to address both pathologies?

. Arthroscopic Bankart repair with Remplissage
. Isolated arthroscopic Bankart repair
. Latarjet procedure
. Open capsular shift
. Humeral head structural allografting

Correct Answer & Explanation

. Arthroscopic Bankart repair with Remplissage


Explanation

An engaging Hill-Sachs lesion combined with subcritical (<20%) glenoid bone loss is effectively treated with an arthroscopic Bankart repair combined with remplissage (capsulotenodesis of the infraspinatus into the Hill-Sachs defect).

Question 1580

Topic: Shoulder & Hip Sports

A 21-year-old elite collegiate baseball pitcher presents with pain in the posterior aspect of his throwing shoulder during the late cocking phase of throwing. He has glenohumeral internal rotation deficit (GIRD) of 25 degrees compared to his non-throwing arm. What is the most likely associated arthroscopic finding?

. Anterosuperior labral tear and subscapularis fraying
. Undersurface fraying of the posterior supraspinatus and posterosuperior labral fraying
. Complete full-thickness tear of the supraspinatus
. Bony Bankart lesion
. Type IV SLAP tear

Correct Answer & Explanation

. Anterosuperior labral tear and subscapularis fraying


Explanation

This classic presentation describes internal impingement. It occurs during extreme abduction and external rotation, causing the undersurface of the posterior supraspinatus and anterior infraspinatus to impinge against the posterosuperior glenoid labrum, leading to fraying.