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Question 1941

Topic: Shoulder & Hip Sports

A 31-year-old professional volleyball player presents with painless weakness in shoulder external rotation. Abduction strength is normal. MRI demonstrates a paralabral cyst causing nerve compression. Where is the cyst most likely located?

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

Correct Answer & Explanation

. Spinoglenoid notch


Explanation

Isolated weakness of the infraspinatus (external rotation) with normal supraspinatus function (abduction) indicates suprascapular nerve entrapment at the spinoglenoid notch. Compression at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 1942

Topic: Shoulder & Hip Sports

A 22-year-old contact athlete experiences recurrent anterior shoulder dislocations. CT imaging demonstrates a 25% anteroinferior glenoid bone loss. Which of the following is the most appropriate definitive surgical management?

. Arthroscopic Bankart repair
. Arthroscopic Remplissage
. Latarjet procedure
. Open Bankart repair
. Putti-Platt procedure

Correct Answer & Explanation

. Latarjet procedure


Explanation

The Latarjet procedure (coracoid transfer) is indicated for anterior shoulder instability in patients with greater than 20-25% glenoid bone loss. Soft tissue repairs alone have an unacceptably high failure rate in young contact athletes with significant bone loss.

Question 1943

Topic: Shoulder & Hip Sports

A 45-year-old male presents with shoulder pain and weakness following a fall. Physical examination reveals a positive bear hug test and a positive belly press test. Which of the following rotator cuff tendons is most likely injured?

. Supraspinatus
. Infraspinatus
. Teres minor
. Subscapularis
. Teres major

Correct Answer & Explanation

. Subscapularis


Explanation

The bear hug and belly press tests are highly sensitive and specific for evaluating subscapularis integrity. These tests isolate the subscapularis function from the other internal rotators like the pectoralis major.

Question 1944

Topic: Shoulder & Hip Sports

A 28-year-old elite volleyball player complains of vague posterior shoulder pain and weakness. Examination shows isolated atrophy of the infraspinatus. An MRI confirms a paralabral cyst causing nerve compression. Where is the most likely location of this cyst?

. Suprascapular notch
. Spinoglenoid notch
. Quadrilateral space
. Triangular interval
. Supraclavicular fossa

Correct Answer & Explanation

. Spinoglenoid notch


Explanation

Entrapment of the suprascapular nerve at the spinoglenoid notch results in isolated infraspinatus weakness and atrophy. Entrapment at the suprascapular notch would affect both the supraspinatus and the infraspinatus.

Question 1945

Topic: Shoulder & Hip Sports

A 35-year-old male presents with two weeks of sudden, severe, unrelenting right shoulder pain. As the pain subsides, he develops profound weakness in shoulder abduction and external rotation. EMG shows denervation of the deltoid and supraspinatus. What is the most likely diagnosis?

. Cervical spondylotic myelopathy
. Massive rotator cuff tear
. Parsonage-Turner syndrome (Neuralgic amyotrophy)
. Pancoast tumor
. Adhesive capsulitis

Correct Answer & Explanation

. Parsonage-Turner syndrome (Neuralgic amyotrophy)


Explanation

Parsonage-Turner syndrome presents with an acute onset of severe, unrelenting shoulder pain followed by patchy muscle weakness and atrophy as the pain subsides. It is an idiopathic brachial neuritis typically treated supportively.

Question 1946

Topic: Shoulder & Hip Sports

A 45-year-old recreational tennis player has persistent shoulder pain despite 6 months of nonoperative management. An MRI arthrogram shows an isolated Type II SLAP tear. What is the most predictable surgical treatment to relieve his pain and restore function?

. Arthroscopic SLAP repair with suture anchors
. Biceps tenodesis
. Biceps tenotomy
. Arthroscopic extensive labral debridement
. Open anterior Bankart repair

Correct Answer & Explanation

. Biceps tenodesis


Explanation

In patients over age 40, biceps tenodesis provides more predictable pain relief and functional improvement for Type II SLAP tears compared to arthroscopic SLAP repair, which carries a higher rate of stiffness in this age group.

Question 1947

Topic: Shoulder & Hip Sports

A 45-year-old man presents with chronic shoulder pain and stiffness after a seizure 6 weeks ago. Physical examination reveals an inability to externally rotate the shoulder beyond neutral. An axillary radiograph shows a defect on the anteromedial humeral head engaging the posterior glenoid. The defect involves 30% of the articular surface. What is the most appropriate surgical management?

. Closed reduction and spica cast
. Open reduction and subscapularis transfer (McLaughlin procedure)
. Arthroscopic Bankart repair
. Anatomic total shoulder arthroplasty
. Latarjet procedure

Correct Answer & Explanation

. Open reduction and subscapularis transfer (McLaughlin procedure)


Explanation

The patient has a missed posterior shoulder dislocation with a reverse Hill-Sachs lesion. For defects involving 25-40% of the articular surface, transfer of the subscapularis or lesser tuberosity into the defect is recommended.

Question 1948

Topic: Shoulder & Hip Sports

A 28-year-old professional volleyball player presents with insidious onset of poorly localized posterior shoulder pain and weakness in external rotation. Examination reveals isolated atrophy of the infraspinatus. MRI demonstrates a paralabral cyst in the spinoglenoid notch. Which labral tear is most commonly associated with this pathology?

. Anterior Bankart tear
. Posterior labral tear
. Superior labral anterior-to-posterior (SLAP) tear
. Inferior labral tear
. Kim lesion

Correct Answer & Explanation

. Posterior labral tear


Explanation

Paralabral cysts in the spinoglenoid notch cause isolated compression of the suprascapular nerve branch to the infraspinatus. These cysts are most commonly associated with posterior labral tears.

Question 1949

Topic: Shoulder & Hip Sports

A 55-year-old manual laborer presents with chronic, severe shoulder weakness. He has an intact subscapularis, but MRI shows a massive, retracted, and fatty-infiltrated tear of the supraspinatus and infraspinatus (Goutallier stage 4). He has no glenohumeral arthritis. Which of the following is the most appropriate surgical option?

. Arthroscopic primary repair
. Latissimus dorsi tendon transfer
. Pectoralis major tendon transfer
. Total shoulder arthroplasty
. Superior capsular reconstruction with subscapularis release

Correct Answer & Explanation

. Latissimus dorsi tendon transfer


Explanation

For a young or active patient with an irreparable posterosuperior rotator cuff tear without arthritis and an intact subscapularis, a latissimus dorsi tendon transfer is an appropriate salvage procedure.

Question 1950

Topic: Shoulder & Hip Sports

A 21-year-old rugby player has recurrent anterior shoulder dislocations. Imaging reveals a 25% anterior glenoid bone loss and an engaging Hill-Sachs lesion. He undergoes a Latarjet procedure. Which structure is carefully preserved and utilized to create a "sling" effect during this procedure?

. Pectoralis minor
. Coracoacromial ligament
. Conjoint tendon
. Long head of the biceps
. Subscapularis upper third

Correct Answer & Explanation

. Conjoint tendon


Explanation

The Latarjet procedure involves transferring the coracoid process with the attached conjoint tendon through a split in the subscapularis. The conjoint tendon acts as a dynamic sling to prevent anterior translation of the humerus.

Question 1951

Topic: Shoulder & Hip Sports

A 25-year-old professional tennis player presents with posterior shoulder pain during the cocking phase of serving. Exam shows a positive relocation test and glenohumeral internal rotation deficit (GIRD) of 25 degrees compared to the contralateral side. What is the primary pathophysiologic mechanism of his shoulder pain?

. Compression of the suprascapular nerve
. Impingement of the undersurface of the rotator cuff against the posterosuperior glenoid
. Subacromial impingement of the bursal surface of the rotator cuff
. Traction injury to the long thoracic nerve
. Tear of the inferior glenohumeral ligament

Correct Answer & Explanation

. Impingement of the undersurface of the rotator cuff against the posterosuperior glenoid


Explanation

Internal impingement involves the pathologic contact of the articular surface of the supraspinatus and infraspinatus tendons against the posterosuperior glenoid and labrum during extreme abduction and external rotation.

Question 1952

Topic: Shoulder & Hip Sports

A 42-year-old man presents with a locked posterior shoulder dislocation after a seizure. CT scan reveals an anteromedial humeral head defect (reverse Hill-Sachs lesion) involving 30% of the articular surface. Which of the following is the most appropriate surgical management?

. Closed reduction and spica cast immobilization
. Arthroscopic Bankart repair alone
. Transfer of the lesser tuberosity into the defect (Modified McLaughlin procedure)
. Total shoulder arthroplasty
. Osteochondral allograft reconstruction

Correct Answer & Explanation

. Transfer of the lesser tuberosity into the defect (Modified McLaughlin procedure)


Explanation

For reverse Hill-Sachs lesions involving 20% to 40% of the articular surface, transferring the lesser tuberosity and subscapularis tendon into the defect (Modified McLaughlin) prevents engagement. Defects >40% typically require arthroplasty.

Question 1953

Topic: Shoulder & Hip Sports

A 22-year-old rugby player presents with recurrent anterior shoulder instability. A 3D CT scan reveals a 26% anterior glenoid bone loss. Which of the following is the most appropriate surgical intervention?

. Arthroscopic Bankart repair with superior capsular shift
. Arthroscopic remplissage alone
. Coracoid transfer (Latarjet procedure)
. Open capsulolabral repair
. Putti-Platt procedure

Correct Answer & Explanation

. Coracoid transfer (Latarjet procedure)


Explanation

Critical glenoid bone loss (>20-25%) in a young, high-demand athlete is an absolute indication for a bony augmentation procedure, such as the Latarjet procedure. Soft tissue repairs alone have an unacceptably high failure rate in this setting.

Question 1954

Topic: Shoulder & Hip Sports

A 29-year-old professional tennis player reports progressive weakness in his serving arm. Examination demonstrates normal supraspinatus strength but 3/5 strength in external rotation with the arm at the side. Atrophy is noted only in the infraspinatus fossa. Where is the most likely location of nerve compression?

. Suprascapular notch
. Quadrilateral space
. Spinoglenoid notch
. Triangular interval
. Cervical neural foramen (C5)

Correct Answer & Explanation

. Spinoglenoid notch


Explanation

Compression of the suprascapular nerve at the spinoglenoid notch affects only the infraspinatus muscle, leading to isolated external rotation weakness. Compression at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 1955

Topic: Shoulder & Hip Sports

A 21-year-old baseball pitcher presents with posterior shoulder pain during the late cocking phase of throwing. MRI arthrogram shows undersurface fraying of the posterior supraspinatus and anterior infraspinatus tendons, along with posterosuperior labral fraying. What is the primary pathoanatomic mechanism?

. Subcoracoid impingement
. Subacromial impingement
. Internal impingement
. Quadrilateral space syndrome
. Adhesive capsulitis

Correct Answer & Explanation

. Internal impingement


Explanation

Internal impingement occurs in overhead athletes when the undersurface of the posterosuperior rotator cuff abuts the posterosuperior glenoid labrum during maximum abduction and external rotation (late cocking phase).

Question 1956

Topic: Shoulder & Hip Sports

A 65-year-old man undergoes repair of a massive anterior rotator cuff tear (subscapularis) that is deemed irreparable intraoperatively. Which of the following tendon transfers is the most established option for restoring function?

. Latissimus dorsi transfer
. Lower trapezius transfer
. Pectoralis major transfer
. Biceps tenodesis
. Rhomboid major transfer

Correct Answer & Explanation

. Pectoralis major transfer


Explanation

Transfer of the pectoralis major (specifically the sternal head or the entire tendon routed deep to the conjoined tendon) to the lesser tuberosity is the gold standard tendon transfer for an irreparable subscapularis tear.

Question 1957

Topic: Shoulder & Hip Sports

During physical examination of a patient with suspected rotator cuff pathology, the 'Bear Hug' test and the 'Belly-Press' test are positive, but the 'Lift-Off' test is negative. Which anatomical portion of the subscapularis is most likely torn?

. Upper third
. Middle third
. Lower third
. The entire subscapularis
. The insertion on the greater tuberosity

Correct Answer & Explanation

. Lower third


Explanation

The 'Bear Hug' and 'Belly-Press' tests are highly sensitive for upper subscapularis tears. The 'Lift-Off' test requires internal rotation behind the back, which primarily isolates the lower portion of the subscapularis muscle.

Question 1958

Topic: Shoulder & Hip Sports

A 22-year-old professional rugby player presents with his fourth anterior shoulder dislocation. Advanced imaging reveals 25% anterior glenoid bone loss and an engaging Hill-Sachs lesion. Which of the following is the most appropriate surgical management?

. Arthroscopic Bankart repair alone
. Latarjet procedure
. Arthroscopic remplissage alone
. Open Bankart repair without bone grafting
. Proximal humerus derotational osteotomy

Correct Answer & Explanation

. Latarjet procedure


Explanation

In collision athletes with significant anterior glenoid bone loss (>20-25%), isolated soft-tissue repairs have an unacceptably high failure rate. The Latarjet procedure (coracoid transfer) is the gold standard as it reconstructs the glenoid defect and provides a dynamic sling effect.

Question 1959

Topic: Shoulder & Hip Sports

A 28-year-old male volleyball player complains of vague posterior shoulder pain and isolated weakness in external rotation. Examination reveals normal internal rotation and abduction strength, but noticeable atrophy of the infraspinatus fossa. Which of the following is the most likely diagnosis?

. Suprascapular nerve entrapment at the suprascapular notch
. Axillary nerve injury
. Quadrilateral space syndrome
. Suprascapular nerve entrapment at the spinoglenoid notch
. Parsonage-Turner syndrome

Correct Answer & Explanation

. Suprascapular nerve entrapment at the spinoglenoid notch


Explanation

Entrapment of the suprascapular nerve at the spinoglenoid notch selectively involves the branch to the infraspinatus, causing isolated external rotation weakness. Entrapment at the suprascapular notch would also involve the supraspinatus, resulting in abduction weakness.

Question 1960

Topic: Shoulder & Hip Sports

A 45-year-old manual laborer presents with an irreparable, massive, retracted posterosuperior rotator cuff tear. His subscapularis is completely intact. He demonstrates profound weakness in external rotation with a positive Hornblower's sign, but no glenohumeral arthritis. Which of the following is the most appropriate surgical option?

. Reverse total shoulder arthroplasty
. Latissimus dorsi transfer
. Lower trapezius transfer
. Superior capsule reconstruction
. Pectoralis major transfer

Correct Answer & Explanation

. Lower trapezius transfer


Explanation

For a young patient with an irreparable posterosuperior tear and severe external rotation deficit, a tendon transfer is indicated. Lower trapezius transfer is favored because its line of pull closely mimics the native infraspinatus, making it superior to latissimus transfer for restoring external rotation.