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Question 3941

Topic: Shoulder & Hip Sports

A 22-year-old rugby player presents with recurrent anterior shoulder dislocations. Advanced imaging demonstrates 25% glenoid bone loss and an engaging Hill-Sachs lesion. What is the most appropriate definitive surgical management?

. Arthroscopic Bankart repair
. Open Bankart repair with capsular shift
. Latarjet procedure
. Remplissage procedure alone
. Humeral head osteochondral allograft

Correct Answer & Explanation

. Arthroscopic Bankart repair


Explanation

For anterior shoulder instability with >20-25% glenoid bone loss and an engaging Hill-Sachs lesion, a Latarjet procedure (coracoid transfer) is the standard of care to restore joint stability.

Question 3942

Topic: Shoulder & Hip Sports

A 55-year-old laborer suffers from chronic shoulder pain and pseudoparalysis of external rotation. MRI reveals a massive, retracted, and fatty-infiltrated tear of the supraspinatus and infraspinatus with an intact subscapularis. Which of the following tendon transfers is most appropriate for restoring active external rotation?

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

Correct Answer & Explanation

. Pectoralis major


Explanation

Latissimus dorsi tendon transfer is classically indicated to restore active external rotation and forward elevation in patients with massive, irreparable posterosuperior rotator cuff tears and an intact subscapularis.

Question 3943

Topic: Shoulder & Hip Sports

A 45-year-old male presents with shoulder pain and weakness in internal rotation after a fall. Which of the following physical examination tests is most sensitive and specific for evaluating a tear of the upper border of the subscapularis tendon?

. Bear hug test
. Napoleon (belly-press) test
. Lift-off test
. Hornblower's sign
. O'Brien's test

Correct Answer & Explanation

. Bear hug test


Explanation

The bear hug test is highly sensitive and specific for evaluating tears of the upper portion of the subscapularis tendon, whereas the lift-off test primarily isolates the lower portion.

Question 3944

Topic: Shoulder & Hip Sports

A 30-year-old weightlifter presents with vague posterior shoulder pain and a positive jerk test. Nonoperative management has failed. Imaging shows a posterior labral tear without significant glenoid bone loss. What is the most appropriate surgical intervention?

. Arthroscopic posterior labral repair
. Putti-Platt procedure
. Posterior bone block
. Coracoid transfer to the posterior glenoid
. Rotator interval closure alone

Correct Answer & Explanation

. Arthroscopic posterior labral repair


Explanation

Arthroscopic posterior labral repair is the surgical treatment of choice for recurrent posterior shoulder instability in patients who have failed conservative management and lack significant bone loss.

Question 3945

Topic: 5. Sports Medicine

A 24-year-old professional baseball pitcher is diagnosed with an isolated Type II SLAP tear after failing 6 months of physical therapy. What is the recommended surgical management?

. Biceps tenodesis
. Biceps tenotomy
. Arthroscopic repair of the superior labrum
. Diagnostic arthroscopy and debridement only
. Mumford procedure

Correct Answer & Explanation

. Biceps tenodesis


Explanation

In young, overhead athletes (typically <30 years old), arthroscopic repair of a type II SLAP tear is the preferred treatment to restore throwing mechanics, whereas older patients often undergo biceps tenodesis.

Question 3946

Topic: Shoulder & Hip Sports

A 22-year-old throwing athlete experiences posterior shoulder pain during the late cocking phase. An MRI arthrogram reveals a partial articular-sided supraspinatus tendon tear and posterosuperior labral fraying. This condition is primarily associated with which of the following pathomechanics?

. Glenohumeral internal rotation deficit (GIRD)
. Subacromial spurring
. Anterosuperior labral tear
. Scapular winging
. Coracohumeral ligament contracture

Correct Answer & Explanation

. Glenohumeral internal rotation deficit (GIRD)


Explanation

Internal impingement in overhead throwers is heavily associated with glenohumeral internal rotation deficit (GIRD), which is caused by a contracted posteroinferior capsule.

Question 3947

Topic: Shoulder & Hip Sports

A 32-year-old athlete presents with isolated weakness in external rotation of the shoulder. MRI reveals a paralabral cyst causing nerve compression. Where is the cyst most likely located and which muscle will demonstrate isolated atrophy?

. Suprascapular notch; supraspinatus and infraspinatus
. Spinoglenoid notch; isolated infraspinatus
. Spinoglenoid notch; isolated teres minor
. Quadrilateral space; deltoid and teres minor
. Spiral groove; brachioradialis

Correct Answer & Explanation

. Suprascapular notch; supraspinatus and infraspinatus


Explanation

The suprascapular nerve innervates the supraspinatus before passing through the spinoglenoid notch. A cyst at this notch compresses the nerve distally, resulting in isolated infraspinatus atrophy.

Question 3948

Topic: Shoulder & Hip Sports

A 72-year-old man presents with progressive pseudoparalysis and severe glenohumeral osteoarthritis secondary to a massive rotator cuff tear. Which of the following is an absolute contraindication to performing a reverse total shoulder arthroplasty in this patient?

. Intact coracoacromial ligament
. Non-functioning deltoid muscle
. Complete absence of the subscapularis tendon
. Severe fatty infiltration of the infraspinatus
. History of previous arthroscopic rotator cuff debridement

Correct Answer & Explanation

. Intact coracoacromial ligament


Explanation

Reverse total shoulder arthroplasty relies on a functioning deltoid muscle to elevate the arm. A non-functioning deltoid or paralyzed axillary nerve is an absolute contraindication.

Question 3949

Topic: Shoulder & Hip Sports

A 65-year-old male undergoes an arthroscopic biceps tenotomy for a symptomatic superior labral tear and associated biceps tendinopathy. Compared to biceps tenodesis, biceps tenotomy is associated with a significantly higher incidence of which of the following?

. Postoperative stiffness
. Deep space infection
. "Popeye" deformity
. Anterior shoulder pain
. Rotator cuff retear

Correct Answer & Explanation

. Postoperative stiffness


Explanation

Biceps tenotomy has a significantly higher rate of a cosmetic "Popeye" deformity and subjective muscle cramping compared to biceps tenodesis, though clinical shoulder outcome scores are similar.

Question 3950

Topic: Shoulder & Hip Sports

A 22-year-old rugby player presents with recurrent anterior shoulder instability. CT evaluation demonstrates a 25% anteroinferior glenoid bone loss (an "inverted pear" glenoid). What is the most appropriate surgical management?

. Arthroscopic Bankart repair
. Arthroscopic Bankart repair with remplissage
. Open capsular shift
. Coracoid transfer (Latarjet procedure)
. Humeral head structural allograft

Correct Answer & Explanation

. Arthroscopic Bankart repair


Explanation

In patients with significant glenoid bone loss (typically >20-25%), soft tissue stabilization (Bankart repair) has an unacceptably high failure rate. A coracoid transfer (Latarjet procedure) is the gold standard to restore the glenoid arc and provide a dynamic sling effect.

Question 3951

Topic: Shoulder & Hip Sports

During an arthroscopic stabilization for recurrent shoulder instability, an engaging Hill-Sachs lesion is noted with minimal glenoid bone loss. Which of the following procedures is indicated to address the humeral defect?

. Coracoid transfer to the anterior glenoid
. Infraspinatus tenodesis and posterior capsulodesis (Remplissage)
. Iliac crest bone graft to the humerus
. Arthroscopic subscapularis repair
. Humeral head resurfacing

Correct Answer & Explanation

. Coracoid transfer to the anterior glenoid


Explanation

An engaging Hill-Sachs lesion without critical glenoid bone loss is effectively treated with a remplissage procedure. This involves tenodesis of the infraspinatus and posterior capsule into the defect, preventing it from engaging the anterior glenoid rim during external rotation and abduction.

Question 3952

Topic: 5. Sports Medicine

A 28-year-old overhead athlete presents with persistent shoulder pain. MRI arthrogram reveals a partial articular-sided supraspinatus tendon avulsion (PASTA) involving 60% of the tendon footprint. Conservative management has failed. What is the recommended surgical approach?

. Arthroscopic debridement alone
. Subacromial decompression alone
. Biceps tenodesis
. Completion of the tear and repair or in situ repair
. Superior capsular reconstruction

Correct Answer & Explanation

. Arthroscopic debridement alone


Explanation

Partial articular-sided rotator cuff tears involving greater than 50% of the tendon footprint typically require surgical repair. This can be accomplished via tear completion and formal repair, or a transtendon in situ repair to restore the footprint without violating the intact bursal fibers.

Question 3953

Topic: Shoulder & Hip Sports

A 35-year-old man presents with shoulder pain and a locked arm in internal rotation after a first-time seizure. Radiographs reveal a posterior shoulder dislocation with an anteromedial humeral head defect (reverse Hill-Sachs lesion) involving 35% of the articular surface. What is the most appropriate surgical treatment?

. Closed reduction and prolonged sling immobilization
. Arthroscopic posterior labral repair
. Transfer of the subscapularis or lesser tuberosity into the defect
. Latarjet procedure
. Total shoulder arthroplasty

Correct Answer & Explanation

. Closed reduction and prolonged sling immobilization


Explanation

Posterior dislocations with an anteromedial humeral head defect (reverse Hill-Sachs) between 20% and 40% are typically treated with a McLaughlin or modified McLaughlin procedure. This involves transferring the subscapularis or lesser tuberosity into the defect to provide dynamic stability.

Question 3954

Topic: Shoulder & Hip Sports

A 55-year-old male sustains an acute traumatic anterior shoulder dislocation. After successful reduction, he complains of profound weakness in internal rotation. Which of the following physical examination tests is most sensitive for diagnosing an upper subscapularis tendon tear?

. Jobe's test (Empty can test)
. Hornblower's sign
. Bear hug test
. Speed's test
. Neer impingement sign

Correct Answer & Explanation

. Jobe's test (Empty can test)


Explanation

The Bear hug test is highly sensitive and specific for diagnosing tears of the upper subscapularis tendon. The lift-off test is also used but primarily isolates the lower subscapularis and requires the patient to be able to internally rotate the arm behind the back.

Question 3955

Topic: 5. Sports Medicine

During an arthroscopy for recurrent anterior shoulder instability, the surgeon identifies an Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) lesion. How does this pathology differ anatomically from a classic Bankart lesion?

. The anterior scapular periosteum remains intact and the labrocapsular complex is displaced medially.
. The periosteum is completely torn and the labrum floats freely in the joint.
. It involves an avulsion of the glenohumeral ligaments from their humeral insertion.
. It is obligatorily associated with a greater tuberosity fracture.
. It involves a tear of the superior labrum from anterior to posterior.

Correct Answer & Explanation

. The anterior scapular periosteum remains intact and the labrocapsular complex is displaced medially.


Explanation

An ALPSA lesion involves an intact anterior scapular periosteum that strips off the bone, allowing the avulsed labroligamentous complex to displace medially. It often heals in a non-anatomic position on the glenoid neck, unlike a classic Bankart which has a ruptured periosteum.

Question 3956

Topic: Shoulder & Hip Sports

A 30-year-old professional volleyball player presents with posterior shoulder pain and isolated weakness in external rotation. MRI reveals a paralabral cyst located in the spinoglenoid notch. This finding is most commonly associated with which of the following concomitant labral pathologies?

. Anterior Bankart lesion
. Posterior Bankart lesion
. Type II SLAP tear
. ALPSA lesion
. HAGL lesion

Correct Answer & Explanation

. Anterior Bankart lesion


Explanation

Paralabral cysts in the spinoglenoid notch typically compress the infraspinatus branch of the suprascapular nerve, causing isolated external rotation weakness. They are highly associated with posterior or superior labral tears (often Type II SLAP tears), which act as a one-way valve for joint fluid to escape.

Question 3957

Topic: Shoulder & Hip Sports

A 22-year-old collegiate rugby player presents with recurrent anterior shoulder instability. A 3D CT scan demonstrates a 28% anterior glenoid bone defect. Which of the following is the most appropriate surgical treatment?

. Arthroscopic Bankart repair with capsular plication
. Open Bankart repair
. Coracoid process transfer (Latarjet procedure)
. Remplissage procedure alone
. Arthroscopic superior labrum anterior and posterior (SLAP) repair

Correct Answer & Explanation

. Arthroscopic Bankart repair with capsular plication


Explanation

For anterior glenoid bone loss exceeding 20-25% in a high-demand athlete, an arthroscopic soft-tissue repair has an unacceptably high failure rate. A bony augmentation, such as a Latarjet procedure, is indicated to restore glenoid track stability.

Question 3958

Topic: 5. Sports Medicine

A 40-year-old man presents to the emergency department after suffering a first-time generalized tonic-clonic seizure. He complains of right shoulder pain and his arm is locked in internal rotation. An axillary radiograph reveals a posterior shoulder dislocation with an impaction fracture of the anterior humeral head (reverse Hill-Sachs lesion) involving 30% of the articular surface. What is the most appropriate surgical management?

. Closed reduction and spica casting
. Arthroscopic posterior labral repair
. Transfer of the lesser tuberosity into the defect (Modified McLaughlin)
. Anatomic total shoulder arthroplasty
. Structural allograft reconstruction of the glenoid

Correct Answer & Explanation

. Closed reduction and spica casting


Explanation

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

Question 3959

Topic: 5. Sports Medicine

A 45-year-old heavy laborer presents with deep shoulder pain and a sensation of mechanical catching. MRI arthrogram reveals an isolated Type II SLAP tear. He has failed 6 months of supervised physical therapy and NSAIDs. What is the most reliable surgical option to relieve his symptoms and allow return to work?

. Arthroscopic labral debridement
. Arthroscopic SLAP repair with suture anchors
. Subpectoral biceps tenodesis
. Coracoacromial ligament release
. Diagnostic arthroscopy without intervention

Correct Answer & Explanation

. Arthroscopic labral debridement


Explanation

In older patients (typically >40 years) or heavy laborers, biceps tenodesis provides more reliable pain relief and better functional outcomes than SLAP repair. SLAP repairs in this demographic have higher rates of postoperative stiffness and persistent pain.

Question 3960

Topic: Shoulder & Hip Sports

The stability of the glenohumeral joint relies heavily on balanced force couples. Which of the following muscular combinations forms the critical force couple that provides a compressive force across the joint in the transverse (axial) plane?

. Deltoid and supraspinatus
. Subscapularis and infraspinatus/teres minor
. Pectoralis major and latissimus dorsi
. Trapezius and serratus anterior
. Supraspinatus and coracobrachialis

Correct Answer & Explanation

. Deltoid and supraspinatus


Explanation

The transverse (axial) force couple consists of the subscapularis anteriorly and the infraspinatus/teres minor posteriorly. This couple centers the humeral head dynamically in the glenoid during arm elevation.