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9. Shoulder and Elbow MCQs

Practice Set 113 of 197

This practice set contains high-yield board review questions covering key concepts in 9. Shoulder and Elbow. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 2241

Topic: 9. Shoulder and Elbow

Following arthroscopic rotator cuff repair, a 60-year-old patient develops severe shoulder pain and progressive stiffness that is unresponsive to analgesics and physical therapy. The pain is global and limits both active and passive range of motion in all planes. Radiographs are normal, and there are no signs of infection. What is the MOST likely post-operative complication?

. Re-tear of the rotator cuff
. Deltoid dehiscence
. Adhesive capsulitis (frozen shoulder)
. Subacromial impingement
. Heterotopic ossification

Correct Answer & Explanation

. Re-tear of the rotator cuff

Explanation

Severe, global shoulder pain and progressive stiffness with loss of both active and passive range of motion in all planes following shoulder surgery (especially rotator cuff repair) is a classic presentation of post-operative adhesive capsulitis (frozen shoulder). This is a common and often challenging complication. While a re-tear is possible, it would typically present more with weakness and less with global passive stiffness. Deltoid dehiscence is a rare, severe complication causing significant weakness. Subacromial impingement would cause pain with specific movements but not global stiffness. Heterotopic ossification could cause stiffness but is usually visible on radiographs and less likely to be the primary cause of such diffuse symptoms without other findings.

Question 2242

Topic: 9. Shoulder and Elbow

A 45-year-old female presents with sudden onset of severe, excruciating pain in her right shoulder, which awakens her from sleep. She has extremely limited range of motion due to pain. Radiographs show a large calcific deposit within the supraspinatus tendon. She has no history of trauma. What is the MOST appropriate initial management?

. Arthroscopic debridement of the calcific deposit
. Reverse total shoulder arthroplasty
. Subacromial decompression
. Oral NSAIDs, rest, and subacromial corticosteroid injection
. Physical therapy with stretching exercises

Correct Answer & Explanation

. Arthroscopic debridement of the calcific deposit

Explanation

The patient presents with classic acute calcific tendinitis (calcific periarthritis), characterized by sudden onset of severe, excruciating shoulder pain and severely restricted range of motion, often waking them from sleep, with a visible calcific deposit on radiographs. The acute phase is extremely inflammatory and painful. The MOST appropriate initial management is conservative: pain control with oral NSAIDs, rest, and a subacromial corticosteroid injection. The injection helps to reduce the intense inflammation. While surgery (arthroscopic debridement) is an option for chronic, refractory cases, it is not the initial treatment for acute calcific tendinitis, which often resolves spontaneously. Reverse TSA and subacromial decompression are inappropriate. Physical therapy with aggressive stretching would likely exacerbate the pain in the acute phase.

Question 2243

Topic: 9. Shoulder and Elbow

A 60-year-old male presents with chronic shoulder pain, stiffness, and crepitus. Radiographs show severe glenohumeral osteoarthritis with an intact rotator cuff. He has failed conservative management. He is a low-demand patient with significant medical comorbidities. Which of the following surgical options offers the BEST balance of pain relief, functional improvement, and reduced risk in this patient?

. Anatomic total shoulder arthroplasty
. Hemiarthroplasty
. Reverse total shoulder arthroplasty
. Arthroscopic debridement
. Shoulder fusion

Correct Answer & Explanation

. Anatomic total shoulder arthroplasty

Explanation

For severe glenohumeral osteoarthritis with an intact rotator cuff, anatomic total shoulder arthroplasty (TSA) is the gold standard, providing excellent pain relief and functional improvement. Given his low-demand status and comorbidities, an unconstrained anatomic TSA would be the optimal choice. Hemiarthroplasty replaces only the humeral head, and while less invasive, can lead to persistent glenoid pain and progressive erosion. Reverse total shoulder arthroplasty is for rotator cuff deficiency. Arthroscopic debridement offers temporary relief at best for severe arthritis. Shoulder fusion is a salvage procedure sacrificing motion. Anatomic TSA generally has a good risk-benefit profile in this scenario.

Question 2244

Topic: 9. Shoulder and Elbow

A 70-year-old male with chronic shoulder pain has failed extensive non-operative management. MRI reveals a massive, irreparable supraspinatus and infraspinatus tear, significant fatty infiltration, and severe superior migration of the humeral head (Hamada Stage 4), but no significant glenohumeral arthritis. He has persistent pseudoparalysis. Which of the following is the MOST appropriate surgical intervention?

. Hemiarthroplasty
. Anatomic total shoulder arthroplasty
. Reverse total shoulder arthroplasty
. Latissimus dorsi tendon transfer
. Superior capsular reconstruction

Correct Answer & Explanation

. Hemiarthroplasty

Explanation

This patient presents with a massive, irreparable rotator cuff tear, significant fatty infiltration, and superior migration of the humeral head (rotator cuff tear arthropathy or 'pseudoparalysis' due to mechanical disadvantage of deltoid) butwithoutsignificant glenohumeral arthritis. In this scenario, reverse total shoulder arthroplasty (rTSA) is the gold standard. rTSA repositions the center of rotation and enhances deltoid efficiency, restoring active elevation and providing pain relief, even in the absence of a functional rotator cuff. Hemiarthroplasty and anatomic TSA require an intact rotator cuff. Latissimus dorsi transfer is an option for younger patients with irreparable posterior tears to restore external rotation, but it may not address the pseudoparalysis effectively in older patients. Superior capsular reconstruction is for younger patients without arthritis but with irreparable tears, primarily to prevent superior migration.

Question 2245

Topic: 9. Shoulder and Elbow

A 70-year-old female presents with chronic shoulder pain and a stiff shoulder. Examination reveals severe global loss of active and passive range of motion. Radiographs show significant glenohumeral osteoarthritis. MRI reveals a large, irreparable rotator cuff tear with severe fatty infiltration. She has no pseudoparalysis. What is the MOST appropriate surgical treatment?

. Anatomic total shoulder arthroplasty
. Hemiarthroplasty
. Reverse total shoulder arthroplasty
. Arthroscopic capsular release
. Shoulder fusion

Correct Answer & Explanation

. Anatomic total shoulder arthroplasty

Explanation

This patient has severe glenohumeral osteoarthritis combined with a massive, irreparable rotator cuff tear and severe fatty infiltration, which is classic for rotator cuff arthropathy (Hamada Stage III or IV). For this condition, especially in an elderly patient, reverse total shoulder arthroplasty (rTSA) is the gold standard treatment. rTSA is designed to function independently of the rotator cuff, relying on the deltoid for elevation and rotation, providing both pain relief and functional improvement. Anatomic TSA and hemiarthroplasty rely on a functional rotator cuff and are contraindicated in this scenario. Arthroscopic capsular release would not address the underlying joint destruction or cuff deficiency. Shoulder fusion is a salvage procedure.

Question 2246

Topic: 9. Shoulder and Elbow

A 65-year-old female presents with a new onset of chronic, dull, aching pain in her left shoulder. She has a history of breast cancer with axillary lymph node dissection 5 years ago, followed by radiation therapy. Examination reveals mild lymphedema and limited abduction. Radiographs show no acute findings. What is the MOST concerning diagnosis to rule out?

. Adhesive capsulitis
. Rotator cuff tear
. Glenohumeral osteoarthritis
. Metastatic disease to the proximal humerus or scapula
. Brachial plexopathy from radiation

Correct Answer & Explanation

. Adhesive capsulitis

Explanation

Given the patient's history of breast cancer with axillary lymph node dissection and radiation therapy, new onset of shoulder pain, even if dull and aching, must raise high suspicion for metastatic disease to the bone (proximal humerus or scapula). While adhesive capsulitis, rotator cuff tear, and osteoarthritis are common causes of shoulder pain in this age group, the cancer history makes metastatic disease a critical and urgent diagnosis to rule out. Brachial plexopathy from radiation typically presents with nerve-related symptoms (pain, paresthesias, weakness in a dermatomal/myotomal pattern), which is not the primary complaint here. Therefore, imaging such as bone scan, PET scan, or MRI of the shoulder should be pursued to exclude metastatic disease.

Question 2247

Topic: 9. Shoulder and Elbow

A 70-year-old patient undergoes an anatomic total shoulder arthroplasty for severe glenohumeral osteoarthritis. Six months post-operatively, he complains of persistent pain, grinding, and progressive loss of external rotation. Radiographs show superior migration of the humeral head component and wear of the glenoid component. Which of the following is the MOST likely underlying cause of these findings?

. Glenoid component loosening due to infection
. Rotator cuff tear and failure
. Implant malpositioning
. Adhesive capsulitis
. Deltoid muscle rupture

Correct Answer & Explanation

. Glenoid component loosening due to infection

Explanation

The symptoms of persistent pain, grinding, progressive loss of external rotation, and radiographic findings of superior migration of the humeral head and glenoid component wear after anatomic total shoulder arthroplasty are classic for rotator cuff tear and failure. Anatomic TSA relies on an intact, functional rotator cuff. If the rotator cuff fails (e.g., supraspinatus and infraspinatus), the humeral head is no longer centralized on the glenoid, leading to superior migration, eccentric loading of the glenoid (causing wear), pain, and loss of active rotation. Glenoid loosening can occur but is not always associated with superior humeral migration to this extent without cuff failure. Implant malpositioning could cause issues, but rotator cuff failure is a well-recognized complication. Adhesive capsulitis is global stiffness. Deltoid rupture is less common and would lead to pseudoparalysis.

Question 2248

Topic: 9. Shoulder and Elbow

A 25-year-old male presents with recurrent episodes of shoulder pain and paresthesias in his hand, particularly when carrying heavy objects or with overhead activity. He notes discoloration of his hand (blanching or cyanosis) during these episodes. Examination reveals a positive Adson's test and a positive Roos test. What is the MOST likely diagnosis?

. Rotator cuff tendinitis
. Thoracic outlet syndrome
. Biceps tendinopathy
. Cervical radiculopathy
. Ulnar nerve entrapment at the elbow

Correct Answer & Explanation

. Rotator cuff tendinitis

Explanation

The patient's symptoms of recurrent shoulder pain, hand paresthesias, and hand discoloration (vascular symptoms) exacerbated by overhead activity or carrying heavy objects, combined with positive Adson's test (diminished radial pulse with arm abduction, external rotation, and head turning to the affected side) and Roos test (elevated arm stress test), are highly suggestive of thoracic outlet syndrome (TOS). TOS involves compression of the neurovascular bundle (brachial plexus, subclavian artery/vein) in the thoracic outlet. Rotator cuff tendinitis and biceps tendinopathy primarily cause localized shoulder pain. Cervical radiculopathy would cause dermatomal/myotomal symptoms. Ulnar nerve entrapment is distal to the shoulder and would not cause vascular symptoms in the hand or positive TOS provocative tests.

Question 2249

Topic: 9. Shoulder and Elbow

A 60-year-old male undergoes arthroscopic rotator cuff repair. Post-operatively, he develops significant pain and stiffness, with limited active and passive range of motion. MRI confirms a healed rotator cuff repair, but shows severe thickening and contracture of the joint capsule. What is the MOST likely diagnosis?

. Re-tear of the rotator cuff
. Adhesive capsulitis (frozen shoulder)
. Glenohumeral osteoarthritis
. Impingement syndrome
. Long thoracic nerve injury

Correct Answer & Explanation

. Re-tear of the rotator cuff

Explanation

The patient's presentation of significant post-operative pain, stiffness, and global loss of active and passive range of motion, with a healed rotator cuff repair and capsular thickening/contracture on MRI, is highly characteristic of post-operative adhesive capsulitis (frozen shoulder). This is a well-known complication after shoulder surgery. A re-tear would result in weakness, often without global passive stiffness. Glenohumeral osteoarthritis would typically be pre-existing. Impingement syndrome is typically pain with specific movements. Long thoracic nerve injury would cause scapular winging. The key here is the global loss of both active and passive motion and capsular thickening.

Question 2250

Topic: Elbow & Forearm

A 14-year-old male presents with recurrent acute locking and catching of his elbow, particularly with extension. He denies any recent trauma. Radiographs are normal. What is the MOST likely diagnosis?

. Loose body in the elbow joint
. Osteochondritis dissecans of the capitellum
. Panner's disease
. Olecranon stress fracture
. Medial epicondylitis

Correct Answer & Explanation

. Loose body in the elbow joint

Explanation

Recurrent acute locking and catching of the elbow, especially with extension, in a young patient without acute trauma, is highly suggestive of a loose body (osteochondral fragment) within the joint. These loose bodies can become entrapped in the joint space, causing mechanical symptoms. While osteochondritis dissecans (OCD) of the capitellum is common in young athletes and can lead to loose bodies, the primary diagnosis for acute mechanical locking with normal radiographs would be a loose body, which could be from an undiagnosed prior OCD lesion or other traumatic event. Panner's disease is osteochondrosis of the capitellum in younger children (<10 years) and usually causes diffuse pain and limited motion, not acute locking. Olecranon stress fracture causes posterior pain. Medial epicondylitis causes medial epicondyle pain.

Question 2251

Topic: Shoulder Arthroplasty & Arthritis

A 72-year-old woman with pseudoparalysis secondary to severe rotator cuff tear arthropathy is scheduled for a reverse total shoulder arthroplasty (RTSA). During preoperative templating and intraoperative execution, the surgeon intentionally places the glenosphere with an inferior tilt and an eccentric inferior overhang. This specific technique is primarily intended to minimize the risk of which of the following complications?

. Anterior dislocation
. Acromial stress fracture
. Scapular notching
. Baseplate loosening
. Deltoid dehiscence

Correct Answer & Explanation

. Anterior dislocation

Explanation

Scapular notching is a well-described complication in reverse total shoulder arthroplasty, occurring when the medialized humeral component impinges against the inferior scapular neck during adduction. To prevent this mechanical impingement, surgeons utilize an inferior tilt of the baseplate and ensure an inferior overhang of the glenosphere (usually 2 to 4 mm). This positioning alters the impingement-free arc of motion, reducing the incidence of Sirveaux grading scapular notching.

Question 2252

Topic: Elbow & Forearm

A 42-year-old man falls from a ladder and sustains a 'terrible triad' injury to his right elbow. Surgical intervention is undertaken. After stable internal fixation of the coronoid process fracture and prosthetic replacement of the comminuted radial head, the elbow drops out of joint when placed in extension and supination. What is the most appropriate next step in the surgical sequence?

. Application of a hinged external fixator
. Repair of the lateral ulnar collateral ligament (LUCL)
. Repair of the medial ulnar collateral ligament (MUCL)
. Release of the common extensor origin
. Fasciotomy of the forearm

Correct Answer & Explanation

. Application of a hinged external fixator

Explanation

The 'terrible triad' of the elbow consists of an elbow dislocation, a radial head fracture, and a coronoid fracture. The standard surgical algorithm progresses from deep to superficial: 1) Fixation of the coronoid to restore the anterior buttress, 2) Repair or replacement of the radial head to restore the lateral column, and 3) Repair of the lateral ulnar collateral ligament (LUCL) to address posterolateral rotatory instability. If the elbow remains unstable in extension after LUCL repair, the next step is typically repair of the medial collateral ligament (MUCL) or application of a hinged external fixator. Since the LUCL has not yet been addressed in this scenario, it is the appropriate next step.

Question 2253

Topic: 9. Shoulder and Elbow

A 48-year-old male bodybuilder undergoes anatomic repair of a completely ruptured distal biceps tendon using a classic two-incision technique. Postoperatively, he develops a severe limitation in both forearm supination and pronation, while elbow flexion and extension remain fully preserved. Radiographs at 4 months post-op demonstrate heterotopic ossification bridging the radius and ulna. This specific complication is most classically associated with which of the following intraoperative technical errors?

. Entrapment of the lateral antebrachial cutaneous nerve
. Subperiosteal dissection exposing the ulna during tunnel creation
. Failure to repair the lacertus fibrosus
. Over-tensioning of the biceps tendon
. Retraction injury to the posterior interosseous nerve (PIN)

Correct Answer & Explanation

. Entrapment of the lateral antebrachial cutaneous nerve

Explanation

Radioulnar synostosis is a devastating complication primarily associated with the two-incision technique for distal biceps tendon repair. It is classically caused by subperiosteal dissection of the ulna or breaching the interosseous membrane during the creation of the ulnar tunnel. This allows osteoprogenitor cells to migrate and bridge the gap between the radius and ulna, blocking forearm rotation. The modified two-incision (Morrey) technique emphasizes staying within the muscle bellies to avoid exposing the ulnar periosteum.

Question 2254

Topic: Shoulder Arthroplasty & Arthritis

A 78-year-old female sustains a comminuted 4-part proximal humerus fracture and undergoes a reverse total shoulder arthroplasty (RTSA). During the procedure, the surgeon meticulously repairs the greater and lesser tuberosities around the prosthesis. Successful postoperative radiographic healing of the greater tuberosity to the proximal humeral shaft is most strongly associated with which of the following clinical outcomes?

. Decreased risk of scapular notching
. Improved active forward elevation
. Improved active external rotation
. Prevention of baseplate loosening
. Reduced risk of acromial stress fracture

Correct Answer & Explanation

. Decreased risk of scapular notching

Explanation

In RTSA performed for proximal humerus fractures, the reverse prosthesis inherently restores active forward elevation by relying on the deltoid muscle. However, active external rotation is primarily driven by the infraspinatus and teres minor, which attach to the greater tuberosity. If the greater tuberosity fails to heal or resorbs, the patient will have profound weakness in active external rotation (often presenting with a positive horn blower's sign) despite good forward elevation. Therefore, tuberosity healing is the strongest predictor of restored active external rotation.

Question 2255

Topic: 9. Shoulder and Elbow

When planning a reverse total shoulder arthroplasty (rTSA) for a patient with rotator cuff tear arthropathy, how does the Grammont-style prosthesis alter the biomechanics of the glenohumeral joint compared to the native anatomy?

. The center of rotation is moved superiorly and laterally
. The center of rotation is moved inferiorly and laterally
. The center of rotation is moved superiorly and medially
. The center of rotation remains unchanged
. The center of rotation is moved inferiorly and medially

Correct Answer & Explanation

. The center of rotation is moved superiorly and laterally

Explanation

The Grammont design of reverse total shoulder arthroplasty medializes and distalizes (moves inferiorly) the center of rotation. This alteration fundamentally changes shoulder biomechanics by tensioning the deltoid and increasing its moment arm. By doing so, it allows the deltoid muscle to recruit more of its fibers (specifically the anterior and posterior heads) to elevate the arm, compensating for the absent rotator cuff.

Question 2256

Topic: Elbow & Forearm

A 40-year-old male undergoes a distal biceps tendon repair via a single-incision anterior approach using a cortical button. Postoperatively, he is unable to extend his metacarpophalangeal joints and thumb interphalangeal joint, but he has strong wrist extension with radial deviation. Which nerve was most likely injured during the procedure?

. Posterior interosseous nerve (PIN)
. Lateral antebrachial cutaneous nerve (LABCN)
. Superficial radial nerve
. Median nerve
. Anterior interosseous nerve (AIN)

Correct Answer & Explanation

. Posterior interosseous nerve (PIN)

Explanation

The posterior interosseous nerve (PIN) is at risk during a single-incision anterior approach for distal biceps repair, especially if the drill or cortical button plunges too deeply through the posterior cortex of the radius. Injury to the PIN results in paralysis of the finger and thumb extensors as well as the extensor carpi ulnaris (ECU). Wrist extension is preserved but deviates radially because the extensor carpi radialis longus (ECRL) is innervated by the radial nerve proper, proximal to the PIN bifurcation.

Question 2257

Topic: 9. Shoulder and Elbow

A 21-year-old collegiate baseball pitcher presents with medial elbow pain and decreased throwing velocity. MRI reveals a high-grade partial tear of the anterior bundle of the ulnar collateral ligament (UCL). Which of the following statements regarding the anterior bundle of the UCL is anatomically and biomechanically correct?

. It originates on the anterior aspect of the medial epicondyle and inserts on the supinator crest
. The posterior band of the anterior bundle is tightest in full extension
. It is the primary restraint to valgus stress at the elbow between 30 and 120 degrees of flexion
. It consists of a single isometric band that maintains constant tension throughout elbow motion
. It is primarily responsible for preventing posterolateral rotatory instability

Correct Answer & Explanation

. It originates on the anterior aspect of the medial epicondyle and inserts on the supinator crest

Explanation

The anterior bundle of the UCL is the primary restraint to valgus stress at the elbow from 30 to 120 degrees of flexion. It originates on the anteroinferior surface of the medial epicondyle and inserts on the sublime tubercle of the anteromedial coronoid. It is not isometric; the anterior band of the anterior bundle is tightest in extension, whereas the posterior band of the anterior bundle is tightest in flexion.

Question 2258

Topic: 9. Shoulder and Elbow

A 22-year-old collegiate baseball pitcher presents with medial elbow pain during the late cocking and early acceleration phases of throwing. Physical examination reveals valgus instability at 30 degrees of elbow flexion. Non-operative management has failed, and an MRI arthrogram confirms a full-thickness tear of the primary restraint to valgus stress at the elbow. During surgical reconstruction, accurate graft tunnel placement is critical. Which of the following describes the precise anatomic origin and insertion of the native ligament being reconstructed?

. Anteroinferior surface of the medial epicondyle to the sublime tubercle on the anteromedial coronoid facet
. Posterior medial epicondyle to the medial margin of the olecranon process
. Central medial epicondyle to the base of the radial tuberosity
. Lateral epicondyle to the annular ligament and supinator crest
. Anterior medial epicondyle to the center of the trochlear notch

Correct Answer & Explanation

. Anteroinferior surface of the medial epicondyle to the sublime tubercle on the anteromedial coronoid facet

Explanation

The anterior bundle of the ulnar collateral ligament (UCL) is the primary restraint to valgus stress of the elbow between 30 and 120 degrees of flexion. It originates from the anteroinferior surface of the medial epicondyle (not the exact center or posterior aspect) and inserts distally on the sublime tubercle, which is located on the anteromedial facet of the coronoid process of the ulna. Accurate identification of these landmarks during UCL reconstruction ('Tommy John' surgery) is critical to restore native joint kinematics and avoid graft anisometry. The posterior bundle is a secondary restraint, and the lateral ulnar collateral ligament (LUCL) restricts varus and posterolateral rotatory instability.

Question 2259

Topic: Elbow & Forearm

A 38-year-old male undergoes a single-incision anterior approach for the repair of a retracted distal biceps tendon rupture using a suspensory cortical button technique. In the recovery room, the patient demonstrates a weak, radially-deviated wrist extension and a complete inability to actively extend his fingers and thumb at the metacarpophalangeal joints. Sensation over the dorsum of the hand is entirely intact. Which of the following is the most likely mechanism for this postoperative complication?

. Iatrogenic laceration of the superficial radial nerve during superficial dissection
. Traction neuropraxia of the posterior interosseous nerve due to forceful lateral retraction
. Thermal necrosis of the median nerve during electrocautery of the recurrent radial artery branches
. Compression of the lateral antebrachial cutaneous nerve by the surgical dressing
. Tethering of the anterior interosseous nerve within the pronator teres

Correct Answer & Explanation

. Iatrogenic laceration of the superficial radial nerve during superficial dissection

Explanation

The patient is exhibiting signs of a Posterior Interosseous Nerve (PIN) palsy. The PIN is purely motor (supplying the extensor digitorum, extensor pollicis longus/brevis, extensor carpi ulnaris, etc.), which explains the loss of digit extension and intact sensation. Wrist extension is preserved but radially deviated because the extensor carpi radialis longus (ECRL) and often the extensor carpi radialis brevis (ECRB) are innervated by the radial nerve proper before it bifurcates. In a single-incision anterior approach to the distal biceps, the PIN is at significant risk within the supinator muscle. The most common mechanism of injury is traction neuropraxia caused by vigorous radial/lateral retraction of the brachioradialis and supinator to visualize the radial tuberosity.

Question 2260

Topic: Shoulder Arthroplasty & Arthritis

A 74-year-old female presents 5 years after undergoing a reverse total shoulder arthroplasty (RTSA) for cuff tear arthropathy. Radiographs reveal progressive bone loss at the inferior scapular neck that extends medially past the inferior screw of the glenoid baseplate, eroding into the central peg. Based on the Sirveaux classification, what is the grade of this complication, and which surgical design alteration at the time of her index procedure would have MOST likely decreased her risk of developing it?

. Sirveaux Grade 3; Superior tilt of the glenosphere
. Sirveaux Grade 2; Superior translation of the glenosphere
. Sirveaux Grade 4; Inferior translation and lateralization of the glenosphere
. Sirveaux Grade 4; Medialization of the center of rotation
. Sirveaux Grade 3; Decreasing the humeral neck-shaft angle to 135 degrees

Correct Answer & Explanation

. Sirveaux Grade 3; Superior tilt of the glenosphere

Explanation

The patient has scapular notching, a frequent complication of RTSA caused by mechanical impingement of the medial humeral cup against the inferior scapular neck during arm adduction. The Sirveaux classification grades this: Grade 1 (notch limited to scapular pillar), Grade 2 (notch reaches the inferior screw), Grade 3 (notch extends over the inferior screw), and Grade 4 (notch extends under the baseplate to the central peg). This patient has Sirveaux Grade 4. Surgical techniques and implant designs that reduce scapular notching include inferior translation of the glenosphere (creating a 2-4 mm inferior overhang), inferior tilt of the baseplate, lateralization of the center of rotation, and using a larger glenosphere diameter. Medialization and superior placement increase the risk of notching.

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