This practice set contains high-yield board review questions covering key concepts in Shoulder Pathology. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.
Question 21
Topic: Shoulder Pathology
During an open distal clavicle excision (Mumford procedure) for AC joint osteoarthritis, the surgeon meticulously resects the distal clavicle. Resecting more than 10-12 mm of the distal clavicle increases the risk of which iatrogenic complication?
Correct Answer & Explanation
. Anterior-posterior instability of the clavicle
Explanation
Resection of greater than 1 cm of the distal clavicle can compromise the superior and posterior AC capsular ligaments, leading to anterior-posterior (horizontal) instability. Care must be taken to preserve these capsular structures during excision.
Question 22
Topic: Shoulder Pathology
A 45-year-old male smoker presents with ischemic changes in his index and middle fingers. Angiography reveals multiple segmental occlusions in the distal digital arteries of both hands with "corkscrew" collaterals, while the ulnar artery at the wrist is normal. What is the most likely diagnosis?
Correct Answer & Explanation
. Hypothenar hammer syndrome
Explanation
Thromboangiitis obliterans (Buerger's disease) typically presents in young male smokers with bilateral, distal segmental occlusions of medium and small vessels. In contrast, Hypothenar hammer syndrome presents with isolated ulnar artery pathology at the hamate due to repetitive trauma.
Question 23
Topic: Shoulder Pathology
A 29-year-old female presents with vague right arm paresthesias, subjective weakness, and coldness in her hand, particularly when reaching overhead. Adson's test is positive, and cervical spine radiographs reveal an accessory cervical rib. Compression of which specific neurovascular structures is most likely responsible for her clinical presentation?
Correct Answer & Explanation
. Lower trunk and subclavian artery
Explanation
Neurogenic thoracic outlet syndrome most commonly involves compression of the lower trunk (C8, T1) of the brachial plexus, producing ulnar-sided symptoms. Arterial thoracic outlet syndrome involves compression of the subclavian artery, often caused by a cervical rib or anomalous first rib.
Question 24
Topic: Shoulder Pathology
The examiner describes the thoraco-abdominal (Hodgson's) approach for excising a hemivertebra. During this procedure, after incising the skin and fat, serratus anterior, external oblique, and latissimus dorsi, and removing the 10th rib subperiosteally, what is the critical next anatomical step to gain access to the retroperitoneum?
Correct Answer & Explanation
. Splitting the costal cartilage to enter the retroperitoneum.
Explanation
Correct Answer: CThe case explicitly describes the Hodgson's approach: 'A key step in this procedure is splitting the costal cartilage to enter the retroperitoneum.' This step allows access to the retroperitoneal space where the spine is located, without entering the peritoneal cavity directly.Option A is incorrectbecause ligation of segmental vessels occurs later, after the retroperitoneum is accessed and the discs are excised, to prepare for vertebral excision.Option B is incorrectbecause the parietal pleura is incisedbeforesplitting the costal cartilage, exposing the lung and diaphragm. The question asks for the stepafterthese initial muscle and rib excisions, specifically to enter the retroperitoneum.Option D is incorrectbecause excision of the discs above and below the hemivertebra occurs after the retroperitoneum is accessed and the diaphragm is divided, as part of the vertebral excision process.Option E is incorrectbecause sweeping away retroperitoneal fascia with swabs occursafterentering the retroperitoneum, to clear the surgical field and expose the vertebral column.
Question 25
Topic: Shoulder Pathology
A 45-year-old male sustains a high-energy traction injury to his right arm. Physical examination reveals massive swelling and marked lateral displacement of the scapula. An angiogram demonstrates a right subclavian artery occlusion. What concomitant neurologic injury is most frequently associated with this diagnosis?
Correct Answer & Explanation
. Complete brachial plexus avulsion
Explanation
The clinical picture describes scapulothoracic dissociation. This devastating closed forequarter amputation equivalent is highly associated with complete brachial plexus avulsions and subclavian vascular injuries.
Question 26
Topic: Shoulder Pathology
A 35-year-old woman complains of shoulder pain and weakness 3 months after a cervical lymph node biopsy. On physical exam, there is lateral winging of the scapula that worsens with resisted shoulder abduction. Which nerve is most likely injured?
Correct Answer & Explanation
. Spinal accessory nerve
Explanation
The spinal accessory nerve (CN XI) innervates the trapezius, and its injury results in lateral scapular winging. This classically occurs after posterior triangle neck surgery, such as a lymph node biopsy.
Question 27
Topic: Shoulder Pathology
A 30-year-old male presents with dull aching pain in his right shoulder and difficulty lifting overhead. On examination, having the patient perform a wall push-up demonstrates pronounced prominence of the medial border of the scapula. An injury to which of the following nerves is the most likely cause?
Correct Answer & Explanation
. Long thoracic nerve
Explanation
Prominence of the medial border of the scapula with forward elevation or wall push-ups indicates medial winging, caused by paralysis of the serratus anterior muscle which is innervated by the long thoracic nerve.
Question 28
Topic: Shoulder Pathology
A 35-year-old female undergoes a posterior cervical lymph node biopsy. Postoperatively, she complains of shoulder weakness and is noted to have lateral winging of the scapula with the shoulder drooping. Which nerve was most likely injured, and which muscle is primarily affected?
Correct Answer & Explanation
. Spinal accessory nerve; trapezius
Explanation
Injury to the spinal accessory nerve (often during posterior triangle neck biopsies) causes trapezius palsy, leading to lateral winging of the scapula. Long thoracic nerve injury causes medial winging due to serratus anterior weakness.
Question 29
Topic: Shoulder Pathology
During an open reduction and internal fixation of a Rockwood Type V AC joint separation, the surgeon is carefully dissecting to expose the coracoid process for coracoclavicular ligament reconstruction. The anatomical illustration below highlights the relevant structures.
Which critical neurovascular structure is at the highest risk of iatrogenic injury if dissection is not meticulously performed, particularly when drilling tunnels through the base of the coracoid?
Correct Answer & Explanation
. Brachial plexus and subclavian vessels
Explanation
Correct Answer: CThe case explicitly states that 'The brachial plexus and subclavian vessels lie inferior and medial to the coracoid process. Extreme caution is required during surgical dissection and drilling around the coracoid to avoid iatrogenic injury.' These structures are immediately adjacent to the coracoid base, making them highly vulnerable during tunnel drilling or aggressive dissection.Option A:The axillary nerve is typically located more inferiorly and posteriorly, wrapping around the surgical neck of the humerus, and is less directly at risk during coracoid exposure for AC joint reconstruction.Option B:The suprascapular nerve passes through the suprascapular notch and is at risk during procedures involving the scapular neck or glenoid, but not typically during coracoid exposure.Option D:The cephalic vein is located more laterally in the deltopectoral groove and, while needing protection, is generally less critical than the major neurovascular bundle medial to the coracoid.Option E:The long thoracic nerve runs along the medial border of the scapula and is at risk during procedures involving the chest wall or scapular dissection, not typically during coracoid exposure.
Question 30
Topic: Shoulder Pathology
A 49-year-old male presents with right shoulder pain and weakness after undergoing open cervical lymph node biopsy approximately one year ago. A pertinent finding from the physical exam is seen in Figure A, with the patient's arms by his side. Physical exam finding with the arms in a position of 90 degrees of forward elevation and 10 degrees of external rotation are shown in Figure B. What nerve is most likely injured?
Correct Answer & Explanation
. Spinal accessory
Explanation
The patient is presenting with lateral scapular winging which is a result of injury to the spinal accessory nerve and resultant trapezius muscle palsy. The spinal accessory nerve is fundamental to scapulothoracic function and essential for scapulohumeral rhythm. This nerve is vulnerable along its superficial course. The majority of injuries to the spinal accessory nerve are iatrogenic and occur secondary to head and neck surgery. There is often a marked delay in recognition and initiating treatment. Surgical treatment with the Eden-Lange transfer lateralizes the levator scapulae and rhomboids (transfer from medial border to lateral border). Camp et al. reviewed the results of 111 patients who underwent operative management of a lesion to the spinal accessory nerve. They found that the majority (~80%) of injuries were sustained iatrogenically and that diagnosis was delayed for approximately 12 months.
Question 31
Topic: Shoulder Pathology
A 32-year-old has diffuse pain, weakness, and limited overhead motion in the shoulder as a result of falling on his outstretched arm 2 months ago. Examination reveals medial scapular winging, and an electromyogram shows denervation of the long thoracic nerve. Management should consist of
Correct Answer & Explanation
. pectoralis major-fascia lata graft transfer to the scapula
Explanation
Most cases of isolated serratus anterior palsy resolve spontaneously, usually within 6 to 9 months after traumatic injury and within 2 years after an infectious cause. Pectoralis major-fascia lata graft is an effective treatment for persistent winging.
Question 32
Topic: Shoulder Pathology
A 50-year-old man reports left shoulder pain and weakness after undergoing a lymph node biopsy in his neck 2 years ago. Examination reveals winging of the left scapula. Electromyography shows denervation of the trapezius. Surgical treatment for this condition involves Review Topic
Correct Answer & Explanation
. pectoralis transfer to the medial border of the scapula.
Explanation
The muscle transfer procedure most commonly performed for trapezius paralysis is the Eden-Lange procedure. Trapezius paralysis in this patient is secondary to iatrogenic injury to the spinal accessory nerve during lymph node biopsy. In this procedure, the levator scapulae and rhomboid minor and major muscles are transferred laterally. Pectoralis transfer to the inferior border of the scapula is used as a dynamic transfer for serratus anterior winging.
Question 33
Topic: Shoulder Pathology
A 19-year-old male collegiate rower has a 3-month history of right shoulder pain. There was no inciting trauma prior to the onset of his pain. He also complains of weakness, particularly in abduction and overhead activity. Examination reveals no range-of-motion deficits. Strength testing of the right shoulder demonstrates 4/5 motor strength in forward elevation and abduction. His Beighton hypermobility score is 3/9. Figure 1 shows his scapular position during a wall pushup maneuver. An EMG would likely reveal damage to what nerve?
Correct Answer & Explanation
. Long thoracic nerve
Explanation
Figure 1 reveals medial scapular winging secondary to weakness of the serratus anterior, which is innervated by the long thoracic nerve. Damage to the long thoracic nerve can occur via repetitive stretching, compression, or iatrogenic injury during a surgical procedure. Lateral thoracic winging is caused by weakness of the trapezius, which is innervated by cranial nerve XI (spinal accessory nerve). The direction of scapular winging is judged by the upper medial border of the scapula. Observation of a period of at least 6 months with serratus anterior strengthening while the nerve recovers is the mainstayof treatment for medial scapular winging.
Question 34
Topic: Shoulder Pathology
Figure 17 shows the clinical photograph of a 45-year-old female tennis player who has right arm pain and weakness with elevation after undergoing a cervical biopsy several months ago. The cause of her shoulder weakness is damage to the:
Correct Answer & Explanation
. spinal accessory nerve, causing shoulder depression with the scapula translated laterally and the inferior angle rotated laterally.
Explanation
DISCUSSION: The patient has primary scapulotrapezius winging caused by surgical damage to the spinal accessory nerve during a lymph node biopsy. Other causes include blunt trauma, traction, and penetrating injuries. With spinal accessory palsy, the shoulder appears depressed and laterally translated because of unopposed serratus anterior muscle function. With primary serratus anterior winging that is the result of long thoracic nerve palsy, the scapula assumes a position of elevation and medial translation with the inferior angle rotated medially. The thoracodorsal nerve innervates the latissimus dorsi and is not associated with scapular winging. REFERENCES: Kuhn JE, Plancher KD, Hawkins RJ: Scapular winging. J Am Acad Orthop Surg 1995;3:319-325. Wright TA: Accessory spinal nerve injury. Clin Orthop 1975;109:15-18.
Question 35
Topic: Shoulder Pathology
A 38-year-old man has winging of the ipsilateral scapula after undergoing a transaxillary resection of the first rib 3 weeks ago. What is the most likely cause of this finding?
Correct Answer & Explanation
. Injury to the long thoracic nerve
Explanation
During transaxillary resection of the first rib, the long thoracic nerve is at risk as it passes either through or posterior to the middle scalene muscle. Injury to this nerve may occur as the result of overly aggressive retraction of the middle scalene during the procedure.
Question 36
Topic: Shoulder Pathology
The clinical photograph shows a palsy of what nerve/associated muscle?
Correct Answer & Explanation
. Long thoracic/serratus anterior
Explanation
The clinical picture reveals medial scapular winging, which involves the serratus anterior muscle, potentially due to an injury to the long thoracic nerve that innervates this muscle. Injury to the long thoracic nerve is usually due to closed trauma, direct compression, traction or stretching injury, a direct blow, or, very rarely, viral infection such as Parsonage-Turner syndrome. The nerve is easily injured in surgical dissection of the axilla, and is predisposed to injury due to its relatively long course, it is small in diameter, and it has little surrounding connective tissue.
Question 37
Topic: Shoulder Pathology
A 20-year-old man sustained a scapular fracture after attempting to grab a beam as he fell through a ceiling at a job site 3 months ago. A clinical photograph is shown in Figure 36. He now reports pain in the anterior shoulder and difficulty with overhead activities. What nerve roots make up the involved peripheral nerve?
Correct Answer & Explanation
. C5-C7
Explanation
DISCUSSION: The patient sustained an injury to the long thoracic nerve, which supplies the serratus anterior. Branches of C5 and C6 enter the scalenus medius, unite in the muscle, and emerge as a single trunk and pass down the axilla. On the surface of the serratus anterior, the long thoracic nerve is joined by the branch from C7 and descends in front of the serratus anterior, providing segmental innervation to the serratus anterior.
Question 38
Topic: Shoulder Pathology
In the most common condition causing a winged scapula, which of the following nerves is affected?
Correct Answer & Explanation
. Long thoracic nerve
Explanation
DISCUSSION: A winged scapula is most often associated with Parsonage-Turner syndrome, a condition thought to be due to an inflammatory or immune-mediated mechanism. Certain muscles are predisposed, particularly the serratus anterior muscle innervated by the long thoracic nerve. Other less common nerve lesions (e.g., the spinal accessory and dorsal scapular nerves) may also cause winged scapulae. REFERENCES: Kline DG, Hudson AR: Nerve Injuries: Operative Results for Major Nerve Injuries, Entrapments and Tumors. Philadelphia, PA, WB Saunders, 1995. van Alfen N, van Engelen BG: The clinical spectrum of neuralgic amyotrophy in 246 cases. Brain 2006;129:438-450.
Question 39
Topic: Shoulder Pathology
A 19-year-old collegiate baseball pitcher presents with anterior shoulder pain. Examination reveals scapular malposition, inferior medial border prominence, coracoid pain, and dyskinesis (SICK scapula syndrome). What is the primary physical therapy focus for this condition?
Correct Answer & Explanation
. Stretching of the serratus anterior
Explanation
SICK scapula syndrome typically involves a tight pectoralis minor and weak scapular stabilizers, namely the serratus anterior and lower trapezius. Rehabilitation focuses on stretching the pectoralis minor (to reduce anterior tilt) and strengthening the serratus anterior and lower trapezius to restore proper scapular kinematics.
Question 40
Topic: Shoulder Pathology
In the most common condition causing a winged scapula, which of the following nerves is affected? Review Topic
Correct Answer & Explanation
. Long thoracic nerve
Explanation
A winged scapula is most often associated with Parsonage-Turner syndrome, a condition thought to be due to an inflammatory or immune-mediated mechanism. Certain muscles are predisposed, particularly the serratus anterior muscle innervated by the long thoracic nerve. Other less common nerve lesions (eg, the spinal accessory and dorsal scapular nerves) may also cause winged scapulae.
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