Orthopedic Shoulder 2026 MCQs: Board Review Part 1

Question 1

Which of the following statements best describes why the ulnar nerve is most prone to neuropathy at the elbow?

Explanation

The ulnar nerve is more prone to neuropathy than the radial or median nerves for many reasons. It has the greatest longitudinal excursion required to accommodate elbow range of motion, subjecting it to potential traction forces. The dimensions of the entrance of the cubital tunnel change with elbow motion, potentially causing compression in flexion. For these two reasons, the ulnar nerve is subjected to both compression and traction during elbow motion. Although it passes between two muscle heads as it enters the forearm, so do the median and radial nerves. Finally, the vascular supply is adequate because of the anastamoses between the superior ulnar collateral artery, the posterior ulnar recurrent artery, and the inferior ulnar collateral artery. Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 369-378. Prevel CD, Matloub HS, Ye Z, Sanger JR, Yousif NJ: The extrinsic blood supply of the ulnar nerve at the elbow: An anatomic study. J Hand Surg Am 1993;18:433-438.

Question 2

Figure 1 shows the radiograph of a 71-year-old man who has had increasing pain and weakness in his shoulder for the past 3 years. Nonsurgical management has failed to provide relief. Examination shows 130 degrees of active forward flexion and intact external rotation strength. During surgery, a 1- x 1-cm rotator cuff tear involving the supraspinatus is encountered. Treatment should include

Explanation

Given the size of the rotator cuff tear, it is likely to be repaired; therefore, the treatment of choice is a total shoulder replacement with rotator cuff repair. Severe rotator cuff insufficiency can lead to early glenoid failure because of superior instability, and glenoid resurfacing should be avoided in those instances. Boyd AD Jr, Thomas WH, Scott RD, Sledge CB, Thornhill TS: Total shoulder arthroplasty versus hemiarthroplasty: Indications for glenoid resurfacing. J Arthroplasty 1990;5:329-336.

Question 3

Which of the following is considered the cause of Milwaukee shoulder, a joint disease similar to rotator cuff arthropathy?

Explanation

Neer and associates focused on mechanical and nutritional factors as the etiology of rotator cuff arthropathy. McCarty and associates, in describing a similar syndrome known as Milwaukee shoulder, focused on an inflammatory cause in proposing the pathogenic role of hydroxyapatite, a basic calcium phosphate. Neer CS II, Craig EV, Fukuda H: Cuff-tear arthropathy. J Bone Joint Surg Am 1983;65:1232-1244.

Question 4

The MRI scan of the shoulder shown in Figure 2 was performed with the arm in abduction and external rotation. The image reveals what condition?

Explanation

Internal impingement of the shoulder is now a well-recognized cause of shoulder pain in the throwing athlete. First described by Walch and associates, it involves contact of the rotator cuff and labrum in the maximally externally rotated and abducted shoulder, such as in the late cocking phase of the throwing motion. Schickendantz and associates have shown this contact to be physiologic in most patients and becoming pathologic with repetitive overhead activity. Schickendantz MS, Ho CP, Keppler L, Shaw BD: MR imaging of the thrower's shoulder: Internal impingement, latissimus dorsi/subscapularis strains, and related injuries. Magn Reson Imaging Clin N Am 1999;7:39-49. Walch G, Boileau P, Noel E, et al: Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: An arthroscopic study. J Shoulder Elbow Surg 1992;1:238-245.

Question 5

Figure 3 shows the radiographs of a 32-year-old man who fell 12 feet onto his outstretched arm and sustained a fracture-dislocation of the elbow. Initial management consisted of closed reduction of the dislocation. Surgical treatment should now include repair or reduction and fixation of the

Explanation

The radiographs show fractures of the coronoid and radial head. The medial collateral ligament has been avulsed from the ulnar insertion, and there is a valgus opening on the medial side. The lateral collateral ligament is always disrupted in elbow dislocations and fracture-dislocations that occur secondary to falls. This is known as the terrible triad injury (dislocation and fractures of the coronoid and radial head); it has a very poor prognosis because of its propensity for recurrent or persistent instability and late arthritis. The principle in treating this injury is to repair all of the injured parts or protect them with a hinged external fixator until they heal. Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 345-354. Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 283-294.

Question 6

It is important to avoid which of the following exercises in the immediate postoperative period after humeral head replacement for an acute four-part fracture?

Explanation

It is critical to withhold active range of motion of the shoulder within the first 6 weeks after arthroplasty for acute fracture to prevent tuberosity avulsion. When radiographic and clinical findings show that the tuberosities are healed, active motion may be instituted, usually at 6 to 8 weeks. Immediate passive range-of-motion exercises, including external rotation with a stick, pendulum, and passive elevation, should begin within the limits of the repair on the day of surgery to prevent stiffness. Hartstock LA, Estes WJ, Murray CA, et al: Shoulder hemiarthroplasty for proximal humerus fractures. Orthop Clin North Am 1998;29:467-475.

Question 7

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?

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. Leffert RD: Thoracic outlet syndrome. J Am Acad Orthop Surg 1994;2:317-325.

Question 8

A 73-year-old man who underwent repair of the left rotator cuff 6 years ago reports good pain relief but notes residual weakness of the left shoulder, especially with overhead tasks. He denies having pain at night and has minimal discomfort with activities of daily living but is dissatisfied with his shoulder strength. Radiographs show an acromiohumeral interval of 2 mm. Appropriate management should consist of

Explanation

An exercise program to strengthen the deltoid and remaining rotator cuff will most likely offer the best results. Revision rotator cuff surgery yields better results in decreasing pain than improving strength and function, and this patient has only minimal pain. Tendon transfers, involving the use of the latissimus dorsi or teres major, have been used when the rotator cuff is deemed irreparable but are not indicated in elderly patients with minimal symptoms. Bigliani LU, Cordasco FA, McIlveen SJ, Musso ES: Operative treatment of failed repairs of the rotator cuff. J Bone Joint Surg Am 1992;74:1505-1515. DeOrio JK, Cofield RH: Results of a second attempt at surgical repair of a failed initial rotator-cuff repair. J Bone Joint Surg Am 1984;66:563-567.

Question 9

A 45-year-old woman has had progressive right shoulder pain for the past 6 months. She notes that the pain disrupts her sleep, she has pain at rest that requires the use of narcotic analgesics, and she has limited use of her left shoulder for most activities of daily living. History reveals the use of corticosteroids for systemic lupus erythematosus. Examination shows diminished range of motion. Radiographs of the right shoulder are shown in Figures 4a and 4b. Treatment should consist of

Explanation

4b Humeral arthroplasty provides excellent pain relief and function for stage IV osteonecrosis with humeral collapse. In late disease with glenoid involvement (stage V), total shoulder arthroplasty is preferred. Some authors have reported satisfactory results with core decompression of the humeral head for early stages of osteonecrosis, but results for stage IV osteonecrosis are less satisfactory when compared with those for humeral arthroplasty. Cruess RL: Steroid-induced avascular necrosis of the head of the humerus: Natural history and management. J Bone Joint Surg Br 1976;58:313-317. LePorte DM, Mont MA, Mohan V, Pierre-Jacques H, Jones LC, Hungerford DS: Osteonecrosis of the humeral head treated by core decompression. Clin Orthop 1998;355:254-260.

Question 10

The relocation test is most reliable for diagnosing anterior subluxation of the glenohumeral joint when

Explanation

The relocation test is most accurate when true apprehension is produced with the arm in combined abduction and external rotation and then relieved when posterior pressure is placed on the humeral head. Pain with this test is a less specific response and may occur with other shoulder disorders such as impingement.

Question 11

A 16-year-old high school pitcher notes acute pain on the medial side of his elbow during a pitch. Examination that day reveals medial elbow tenderness, pain with valgus stress, mild swelling, and loss of extension. Plain radiographs show closed physes and no fracture. Which of the following diagnostic studies will best reveal his injury?

Explanation

The history and findings are consistent with a diagnosis of a sprain of the medial collateral ligament (MCL) of the elbow; therefore, contrast-enhanced MRI is considered the most sensitive and specific study for accurately showing this injury. Arthroscopic visualization of the MCL is limited to the most anterior portion of the anterior bundle only; complete inspection of the MCL using the arthroscope is not possible. CT without the addition of contrast is of no value in this situation. Use of a technetium Tc 99m bone scan is limited to aiding in the diagnosis of occult fracture, a highly unlikely injury in this patient. There are no clinical indications for electromyography. Timmerman LA, Andrews JR: Undersurface tear of the ulnar collateral ligament in baseball players: A newly recognized lesion. Am J Sports Med 1994;22:33-36. Timmerman LA, Schwartz ML, Andrews JR: Preoperative evaluation of the ulnar collateral ligament by magnetic resonance imaging and computed tomography arthrography: Evaluation of 25 baseball players with surgical confirmation. Am J Sports Med 1994;22:26-32.

Question 12

Figures 5a and 5b show the radiographs of a 45-year-old patient. What is the most likely diagnosis?

Explanation

5b Glenoid dysplasia is an uncommon anomaly that usually has a benign course but may result in shoulder pain, arthritis, or multidirectional instability. Shoulder pain and instability often improve with shoulder strengthening exercises. Wirth MA, Lyons FR, Rockwood CA Jr: Hypoplasia of the glenoid: A review of sixteen patients. J Bone Joint Surg Am 1993;75:1175-1184.

Question 13

A 14-year-old boy sustains a twisting injury to his right shoulder and recalls feeling a snap during a wrestling match. Examination shows hesitancy to raise the arm away from the side, diffuse tenderness and swelling of the upper arm, and no evidence of neurovascular compromise. Figures 6a and 6b show an AP radiograph and MRI scan. What is the most likely diagnosis?

Explanation

6b While difficult to appreciate on the AP radiograph of the shoulder, the increased physeal signal demonstrated on the axial MRI scan is consistent with a nondisplaced growth plate fracture. A comparison radiograph of the left shoulder also could be considered and the injured shoulder evaluated for physeal widening. Proximal humeral fractures in children are somewhat unusual, representing less than 1% of all fractures seen in children and only 3% to 6% of all epiphyseal fractures. Physeal injuries are classified according to the Salter-Harris classification scheme. Salter-Harris type I fractures represent approximately 25% of physeal injuries to the proximal humerus in adolescents. The proximal humeral physis is responsible for 80% of the longitudinal growth of the humerus; therefore, there is tremendous potential for remodeling of fractures in this region. Management for nondisplaced Salter-Harris type I fractures is limited to a short period of immobilization followed by a gradual return to activities as clinical symptoms resolve. Curtis RJ, Rockwood CA Jr: Fractures and dislocations of the shoulder in children, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, pp 991-1007.

Question 14

Figure 7 shows the radiograph of an otherwise healthy 65-year-old man who injured his right dominant shoulder while skiing 18 months ago. He did not seek treatment at the time of the injury. He now reports intermittent soreness when playing golf but has no other limitations. Examination reveals full range of motion and no tenderness, but he has slight pain with a crossed arm adduction stress test. He is neurologically intact. Initial management should consist of

Explanation

The radiograph shows a displaced type II distal clavicle fracture with nonunion. Because the patient's symptoms are minimal, the injury can be treated like a grade III acromioclavicular separation. Present management should consist of ice, anti-inflammatory drugs, activity modification, and perhaps physical therapy. If nonsurgical management fails to provide relief, the surgical options are varied with no uniformity in the literature regarding surgical treatment of this injury. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.

Question 15

Figure 8 shows the AP radiograph of a 33-year-old woman who sustained a midshaft clavicle fracture from a motorcycle accident 15 months ago. She continues to have significant pain with activities of daily living. Management should consist of

Explanation

The patient has a symptomatic painful atrophic midclavicular nonunion, and the treatment of choice is rigid internal fixation with a dynamic compression plate and autogenous bone grafting. A tension band effect is desired and achieved by placing the plate superiorly. Excellent success rates of 90% to 100% have been reported using this technique. Intramedullary screw fixation without bone grafting has a decreased success rate. Partial claviculectomy is not a preferred option. Jupiter JB, Leffert RD: Non-union of the clavicle: Associated complications and surgical management. J Bone Joint Surg Am 1987;69:753-760.

Question 16

A 62-year-old patient with rheumatoid arthritis has had pain and instability of the elbow following total elbow replacement 2 years ago. A complete work-up, including aspiration and cultures, is negative. Figures 9a and 9b show the AP and lateral radiographs. Treatment should consist of

Explanation

9b The patient has aseptic loosening of the original semiconstrained prosthesis and significant proximal ulnar bone destruction; therefore, the treatment of choice is revision arthroplasty using a semiconstrained design. Although orthotic stabilization could be used, it will not provide long-term pain relief. Resection arthroplasty after removal of the components may lead to painful instability. Elbow arthrodesis would be difficult with the bone stock loss and is not considered the best option. Two main contraindications to the use of an unconstrained prosthesis are significant bone loss and previous use of a hinged or semiconstrained prosthesis. An ulnar allograft could be combined with the use of a semiconstrained long-stemmed ulnar prosthesis as a treatment modification. Ewald FC, Simmons ED Jr, Sullivan JA, et al: Capitellocondylar total elbow replacement in rheumatoid arthritis: Long-term results. J Bone Joint Surg Am 1993;75:498-507.

Question 17

A 21-year-old football player reports increasing pain and a deformity involving his chest after colliding with another player during a scrimmage. Imaging studies confirm an anterior sternoclavicular dislocation. Management should consist of

Explanation

For the patient with an anterior sternoclavicular dislocation, the most appropriate initial treatment should be symptomatic. Surgical options are usually contraindicated because the incidence of intraoperative and postoperative complications is high. A deformity from an anterior sternoclavicular dislocation is usually well tolerated. Return to play is allowed when symptoms resolve. Rockwood CA Jr: Disorders of the sternoclavicular joint, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1998, vol 1, pp 477-525.

Question 18

During total shoulder replacement for rheumatoid arthritis, fracture of the humeral shaft occurs. An intraoperative radiograph shows a displaced short oblique fracture at the tip of the prosthesis. At this point, the surgeon should

Explanation

The risk of intraoperative fracture in osteopenic rheumatoid bone is significant. Fractures may occur with dislocation of the head and canal reaming, especially while extending and externally rotating the shoulder. If the fracture occurs at the distal tip of the prosthesis, the use of a long-stemmed prosthesis to bypass the fracture site and supplementation with wire cables has been reported with good results. Wright TW, Cofield RH: Humeral fractures after shoulder arthroplasty. J Bone Joint Surg Am 1995;77:1340-1346. Boyd AD Jr, Thornhill TS, Barnes CL: Fractures adjacent to humeral protheses. J Bone Joint Surg Am 1992;74:1498-1504.

Question 19

What is the most common contracture deformity of the spastic shoulder secondary to a cerebrovascular accident?

Explanation

The resultant spasticity and weakness (paresis) following a cerebrovascular accident leads to muscle imbalance that commonly results in contracture of the shoulder in adduction, internal rotation, and varying degrees of forward flexion. In addition, the elbow is usually flexed and the forearm pronated. Braun RM, Botte MJ: Treatment of shoulder deformity in acquired spasticity. Clin Orthop 1999;368:54-65.

Question 20

A 21-year-old collegiate pitcher has had pain in his dominant shoulder for the past 3 months despite management consisting of rest, rehabilitation, and an analysis of throwing mechanics. An arthroscopic photograph from the posterior portal is shown in Figure 10. The biceps anchor to the bone was not detached to probing. Treatment of the lesion to the left of the cannula should consist of arthroscopic

Explanation

The lesion is a variation of a type I superior labrum anterior and posterior lesion; therefore, appropriate treatment is simple debridement. Biceps tenodesis or release is not indicated because the biceps tendon and anchor are intact. There is no indication for labral repair or capsulorraphy. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 261-270.

Question 21

After humeral head replacement for four-part fractures, what is the most commonly reported difficulty?

Explanation

Results show that patients who underwent humeral head replacement for fracture almost routinely report pain relief, but functional reports vary. The most commonly reported difficulty is the use of weight in the overhead position with wide variation in active elevation. Factors found to affect active elevation include age, humeral offset, greater tuberosity positioning, and four-part (as compared with three-part) fractures. Goldman RT, Koval KJ, Cuomo F, Gallagher MA, Zuckerman JD: Functional outcome after humeral head replacement for acute three- and fourth-part proximal humeral fractures. J Shoulder Elbow Surg 1995;4:81-86.

Question 22

Figures 11a and 11b show the AP and lateral radiographs of a 32-year-old patient on hemodialysis who has increasing elbow pain and a visibly growing mass over the extensor surface. Figure 11c shows the photomicrograph of the biopsy specimen. What is the most likely diagnosis?

Explanation

11b 11c The radiographic findings are classic for tumoral calcinosis; they are not consistent with myositis ossificans, fungal granuloma, or hemochromatosis. The condition typically appears as large aggregations of dense calcified lobules confined to the surrounding soft tissues. Hyperphosphatemia is a fundamental factor in many patients with this condition. Tumoral calcinosis also occurs in the setting of chronic renal failure when mineral homeostasis is not controlled. The histologic appearance is essentially a foreign body granuloma reaction. Multilocular cysts with purplish amorphous material are surrounded by thick connective tissue capsules. The fibrous walls contain numerous foreign body giant cells. Surgical excision is indicated if the tumor causes discomfort or interferes with function. Sisson HA, Murray RO, Kemp HBS (eds): Orthopaedic Diagnosis: Clinical, Radiological and Pathological Coordinates. New York, NY, Springer-Verlag, 1984.

Question 23

A 52-year-old man who was a former high school pitcher now reports loss of elbow flexion and extension with pain at the extremes of motion. Nonsurgical management has failed to provide relief. Examination reveals movement from 50 degrees to 110 degrees and is painful only at the limits of motion. A radiograph is shown in Figure 12. Treatment should consist of

Explanation

Based on the history, examination, and radiograph, the patient has typical degenerative arthritis of the elbow. This condition is found almost exclusively in men, and there is almost universally a history of repetitive heavy use or overuse of the elbow. Patients report pain at terminal extension and usually have a flexion contracture. Radiographs reveal osteophytes on the coronoid and olecranon and in the coronoid and olecranon fossae. The osteophytes are often associated with loose bodies that sometimes are attached to the soft tissues. Treatment should consist of removal of all loose bodies and impinging osteophytes using open technique or by arthroscopy. The capsular contractures should be released at the same time. Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 283-294. Morrey BF: Primary degenerative arthritis of the elbow: Treatment by ulnohumeral arthroplasty. J Bone Joint Surg Br 1992;74:409-413. Redden JF, Stanley D: Arthroscopic fenestration of the olecranon fossa in the treatment of osteoarthritis of the elbow. Arthroscopy 1993;9:14-16.

Question 24

A 79-year-old woman with polyarticular rheumatoid arthritis has had progressively increasing right shoulder pain for the past year, and nonsurgical management has failed to provide relief. Her neurologic examination is entirely normal, but she is unable to elevate her arm against gravity. An AP radiograph is shown in Figure 13. Treatment should consist of

Explanation

Because the patient has end-stage rheumatoid arthritis with glenoid and rotator cuff deficiency, humeral arthroplasty is the treatment of choice. When a patient has an intact rotator cuff and there is sufficient glenoid bone stock to implant a glenoid component, total shoulder arthroplasty is the preferred method because it appears to provide more predictable pain relief. Glenohumeral arthrodesis is generally avoided when there is a functional deltoid or rotator cuff. Open synovectomy is appropriate in early rheumatoid disease before articular changes are present. Anterior acromioplasty with coracoacromial ligament resection is avoided in patients with rheumatoid arthritis because this procedure compromises the coracoacromial arch and may result in anterosuperior instability. Neer CS II, Watson KC, Stanton FJ: Recent experience in total shoulder replacement. J Bone Joint Surg Am 1982;64:319-337. Neer CS II: Glenohumeral arthroplasty, in Neer CS II (ed): Shoulder Reconstruction. Philadelphia, PA, WB Saunders, 1990, pp 143-271. Pollock RG, Deliz ED, McIlveen ST, et al: Prosthetic replacement in rotator cuff deficient shoulders. J Shoulder Elbow Surg 1992;1:173-186.

Question 25

A 22-year-old woman has had progressive upper extremity weakness for the past several years. History reveals no pain in her neck or shoulders. Examination reveals scapular winging of both shoulders and weakness in external rotation. She can abduct to only 120 degrees bilaterally, and there is mild supraspinatus weakness. She is otherwise neurologically intact with normal sensation and reflexes; however, she has difficulty whistling. A clinical photograph is shown in Figure 14. What is the most likely diagnosis?

Explanation

Progressive weakness is a common sign with a large differential diagnosis. Nerve, muscle, and joint problems should be excluded when a patient has diffuse weakness and atrophy. Fascioscapulohumeral dystrophy is a rare disease characterized by facial muscle weakness and proximal shoulder muscle weakness. The weakness is usually bilateral, and scapular winging is common. If the scapular winging becomes pronounced, elevation of the shoulder can be affected. In severe cases, scapulothoracic fusion or pectoralis muscle transfer to the scapula may be indicated. Duchenne muscular dystrophy is typically severe and progressive. The other diagnoses are not compatible with the history or the physical findings. Shapiro F, Specht L: The diagnosis and orthopaedic treatment of inherited muscular diseases of childhood. J Bone Joint Surg Am 1993;75:439-454.

Question 26

A 72-year-old female presents with sudden onset of superior shoulder pain 6 months after a reverse total shoulder arthroplasty for rotator cuff tear arthropathy. Radiographs show a displaced fracture of the acromion base (Levy type II). What is the most appropriate initial management?

Explanation

Acromial stress fractures after reverse total shoulder arthroplasty (Levy type I and II) are initially managed conservatively with sling immobilization and activity modification. Nonunion is common but often asymptomatic.

Question 27

A 22-year-old male rugby player presents with recurrent anterior shoulder instability. A CT scan with 3D reconstruction reveals 23% anterior glenoid bone loss. Which of the following surgical procedures is most appropriate?

Explanation

In a collision athlete with significant glenoid bone loss (>20-25%), a bony augmentation procedure like the Latarjet is the standard of care to restore anterior stability. Arthroscopic Bankart repair has an unacceptably high failure rate in this setting.

Question 28

A 65-year-old female sustains a displaced 3-part proximal humerus fracture. Examination reveals decreased sensation over the lateral aspect of the deltoid. Which nerve is most likely injured, and what primary muscle function should be tested?

Explanation

The axillary nerve is frequently injured in proximal humerus fractures, presenting with numbness over the lateral deltoid (regimental badge area) and weakness in shoulder abduction due to deltoid denervation.

Question 29

A 28-year-old male volleyball player presents with insidious onset of vague posterior shoulder pain and weakness in external rotation. MRI reveals a paralabral cyst at the spinoglenoid notch. Which of the following is the most likely physical exam finding?

Explanation

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

Question 30

A 68-year-old male with a massive, irreparable posterosuperior rotator cuff tear and no glenohumeral arthritis presents with pseudoparalysis of the shoulder. He has an intact subscapularis and functioning deltoid. Which of the following is the most appropriate surgical treatment?

Explanation

In an elderly patient with a massive irreparable rotator cuff tear and pseudoparalysis, reverse total shoulder arthroplasty provides the most reliable restoration of active elevation. Latissimus dorsi transfer and superior capsular reconstruction are generally reserved for younger patients without pseudoparalysis.

Question 31

A 32-year-old male weightlifter feels a "pop" in his anterior chest wall while performing a bench press. Examination reveals loss of the anterior axillary fold and weakness in internal rotation and adduction. MRI confirms a complete tear of the pectoralis major at its humeral insertion. What is the recommended treatment?

Explanation

Acute surgical repair of complete pectoralis major ruptures at the humeral insertion in active individuals yields superior cosmetic and functional results compared to nonoperative management or delayed repair.

Question 32

A 60-year-old male presents with increasing pain 18 months after an anatomic total shoulder arthroplasty. Inflammatory markers are mildly elevated. Aspiration yields cloudy fluid, but routine aerobic and anaerobic cultures at 3 days are negative. What is the most likely causative organism?

Explanation

Cutibacterium (formerly Propionibacterium) acnes is a slow-growing, anaerobic gram-positive bacillus that is a leading cause of periprosthetic shoulder infections. It typically requires extended cultures (up to 14 days) to be identified.

Question 33

A 55-year-old female with poorly controlled type II diabetes presents with a 4-month history of insidious onset global shoulder pain and progressively decreasing range of motion. Examination reveals a significant loss of both active and passive external rotation. Radiographs are normal. What is the most appropriate initial treatment?

Explanation

Adhesive capsulitis presents with restricted active and passive motion, particularly external rotation. Initial treatment involves an intra-articular corticosteroid injection combined with gentle physical therapy to reduce inflammation and restore motion.

Question 34

A 25-year-old cyclist falls directly onto the point of his shoulder. Radiographs show a type V acromioclavicular (AC) joint dislocation with 150% superior displacement of the clavicle relative to the acromion. What is the most appropriate management?

Explanation

Type V AC joint injuries involve severe superior displacement of the clavicle due to disruption of the AC and coracoclavicular ligaments and the deltotrapezial fascia. They are typically treated with operative reconstruction.

Question 35

A 19-year-old male presents to the emergency department after a high-speed motor vehicle collision complaining of severe chest pain and dyspnea. Physical exam reveals a palpable depression over the medial clavicle. A CT scan confirms a posterior sternoclavicular dislocation. What is the most appropriate immediate management?

Explanation

Posterior sternoclavicular dislocations are orthopedic emergencies due to the risk of compression to the trachea, esophagus, and great vessels. Closed reduction should be attempted in the operating room with cardiothoracic surgery available in case of vascular injury.

Question 36

A 30-year-old male sustains a midshaft clavicle fracture. Which of the following is considered an absolute indication for open reduction and internal fixation?

Explanation

Absolute indications for operative treatment of clavicle fractures include open fractures, skin tenting threatening to progress to an open fracture, associated neurovascular compromise, and polytrauma.

Question 37

A 26-year-old female presents with weakness and prominence of her right shoulder blade after a viral illness. Physical examination demonstrates medial winging of the scapula, which is accentuated when she pushes against a wall. Which nerve is most likely affected?

Explanation

Medial winging of the scapula is caused by paralysis of the serratus anterior muscle, which is innervated by the long thoracic nerve. Lateral winging is associated with spinal accessory nerve palsy affecting the trapezius.

Question 38

A 45-year-old male sustains a traumatic anterior shoulder dislocation. After reduction, he has persistent weakness in internal rotation and increased passive external rotation compared to the contralateral side. The bear-hug and belly-press tests are positive. What is the most likely diagnosis?

Explanation

A traumatic anterior shoulder dislocation in patients over 40 can be associated with a rotator cuff tear. Weakness in internal rotation, increased passive external rotation, and positive bear-hug and belly-press tests specifically indicate a subscapularis tear.

Question 39

A 24-year-old baseball pitcher presents with vague, deep shoulder pain and a "dead arm" feeling during the late cocking phase of throwing. MRI arthrogram reveals a type II SLAP lesion. Following failure of conservative management, what is the preferred surgical treatment?

Explanation

In young overhead athletes, symptomatic type II SLAP lesions that fail conservative treatment are typically treated with arthroscopic repair of the superior labrum. Biceps tenodesis is often preferred in older patients or non-overhead athletes.

Question 40

A 40-year-old male is brought to the emergency department after suffering a generalized seizure. He complains of severe shoulder pain and cannot externally rotate the arm. An AP radiograph shows a "lightbulb" sign. What is the most likely diagnosis?

Explanation

Posterior shoulder dislocations classically occur following seizures or electrical shocks. They present with the arm locked in internal rotation, and AP radiographs show the "lightbulb" sign due to fixed internal rotation of the humeral head.

Question 41

A 65-year-old male heavy laborer complains of sudden onset of pain and a bulge in his lower arm after lifting a heavy object. He has an obvious "Popeye" deformity but reports minimal pain currently. What is the most appropriate management?

Explanation

Rupture of the long head of the biceps tendon in an older patient typically results in a "Popeye" deformity. It is almost always treated nonoperatively as functional loss is minimal and the pain resolves quickly.

Question 42

A 50-year-old male presents with anterior shoulder pain exacerbated by overhead activities. Physical exam shows a positive Neer and Hawkins test. Radiographs demonstrate a type III acromion and subacromial spurring. MRI shows tendinosis of the supraspinatus without a full-thickness tear. After 6 months of failed conservative treatment, what is the best surgical option?

Explanation

For patients with subacromial impingement and a type III (hooked) acromion who fail comprehensive conservative treatment, arthroscopic subacromial decompression and acromioplasty is the accepted surgical procedure.

Question 43

A 65-year-old male presents with severe shoulder pain and decreased range of motion. Radiographs show joint space narrowing, large inferior osteophytes, and subchondral sclerosis. MRI shows an intact rotator cuff. What is the most appropriate definitive surgical treatment?

Explanation

Anatomic total shoulder arthroplasty is the gold standard treatment for end-stage glenohumeral osteoarthritis in patients with an intact, functioning rotator cuff and sufficient glenoid bone stock.

Question 44

A 22-year-old competitive rugby player sustains his third anterior shoulder dislocation. Imaging reveals an engaging Hill-Sachs lesion and 25% anterior glenoid bone loss. Which of the following is the most appropriate surgical management?

Explanation

In a contact athlete with significant anterior glenoid bone loss (>20%) and an engaging Hill-Sachs lesion, a bony augmentation procedure like the Latarjet is indicated. Soft-tissue only repairs in this setting carry an unacceptably high recurrence rate.

Question 45

A 65-year-old woman presents with severe osteoarthritis of the right shoulder. CT scan reveals a retroverted glenoid of 20 degrees and posterior humeral head subluxation with asymmetric posterior wear. According to the Walch classification, which glenoid type is this?

Explanation

The Walch B2 glenoid is characterized by asymmetric posterior glenoid wear, retroversion, and posterior subluxation of the humeral head. It often requires specific management during shoulder arthroplasty, such as eccentric reaming or augmented components.

Question 46

A 28-year-old elite volleyball player presents with painless weakness in her dominant shoulder. Examination reveals isolated atrophy of the infraspinatus muscle. MRI shows a paralabral cyst. Where is the most likely location of the nerve compression?

Explanation

Compression of the suprascapular nerve at the spinoglenoid notch typically results in isolated weakness and atrophy of the infraspinatus. Compression more proximally at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 47

In reverse total shoulder arthroplasty, the center of rotation is moved in which directions compared to the native shoulder anatomy?

Explanation

RTSA medializes and inferiorizes the center of rotation. This increases the deltoid moment arm and tension, allowing it to compensate for a deficient rotator cuff to elevate the arm.

Question 48

A 32-year-old weightlifter feels a sudden "pop" in his anterior axilla while performing a bench press. Examination reveals loss of the anterior axillary fold and weakness in internal rotation and adduction. MRI confirms a complete tear of the pectoralis major tendon at its humeral insertion. Which of the following is the best treatment?

Explanation

Acute complete ruptures of the pectoralis major tendon at the humeral insertion in active individuals should be managed with surgical repair. Surgery restores strength and cosmetic appearance significantly better than nonoperative management.

Question 49

Which of the following modifications in reverse total shoulder arthroplasty component positioning has been shown to decrease the incidence of scapular notching?

Explanation

Scapular notching is a common complication of RTSA caused by mechanical impingement of the humeral component against the scapular neck. Inferior placement with overhang and an inferior tilt of the glenosphere help reduce this impingement.

Question 50

A 68-year-old man presents with a massive, retracted rotator cuff tear involving the supraspinatus and entire infraspinatus, with Goutallier stage 4 fatty infiltration. He has preserved active forward elevation to 140 degrees but lacks active external rotation. Radiographs show no glenohumeral arthritis. Which procedure is most appropriate?

Explanation

In a younger or active patient with an irreparable posterosuperior cuff tear, absent arthritis, preserved elevation but loss of active external rotation, a latissimus dorsi or lower trapezius tendon transfer is indicated. Superior capsule reconstruction focuses on superior translation, not primarily restoring external rotation.

Question 51

A 52-year-old woman presents with insidious onset of profound shoulder stiffness and pain over the last 4 months. Passive and active ROM are equally restricted. Which systemic condition is most strongly associated with an increased incidence and severity of this disorder?

Explanation

Adhesive capsulitis (frozen shoulder) has a strong association with diabetes mellitus. Diabetic patients have a higher incidence, often bilateral involvement, and a more prolonged, refractory clinical course compared to non-diabetic patients.

Question 52

According to Hertel's radiographic criteria, which of the following features is the most reliable predictor of subsequent avascular necrosis following a proximal humerus fracture?

Explanation

Hertel identified specific radiographic predictors for ischemia of the humeral head, including a short calcar segment (<8 mm metaphyseal extension), disrupted medial hinge, and complex fracture patterns. A short calcar is highly predictive of AVN.

Question 53

A 40-year-old man presents with shoulder pain after a generalized seizure. He holds his arm adducted and internally rotated. He cannot actively or passively externally rotate the shoulder. Radiographs show a "lightbulb" sign. Which associated lesion is most likely present?

Explanation

This patient has a posterior shoulder dislocation, commonly occurring after seizures or electrical shock. It is frequently associated with a reverse Hill-Sachs lesion (impaction fracture of the anteromedial humeral head) and a reverse Bankart lesion.

Question 54

A 38-year-old man presents with sudden, severe, unremitting right shoulder pain lasting for 2 weeks, followed by profound weakness of the shoulder and arm as the pain begins to subside. MRI of the shoulder and cervical spine is normal. EMG reveals denervation in the deltoid and supraspinatus. What is the most likely diagnosis?

Explanation

Brachial neuritis (Parsonage-Turner syndrome) classically presents with acute, severe shoulder girdle pain that transitions to profound weakness and atrophy as the pain improves. It is a self-limiting viral/autoimmune plexopathy.

Question 55

A 20-year-old baseball pitcher presents with vague, deep shoulder pain and a positive O'Brien's test. MRI arthrogram shows a Type II SLAP lesion. After failing a 4-month course of focused physical therapy, what is the recommended surgical treatment?

Explanation

In young, active overhead athletes (under 30-35 years) with symptomatic Type II SLAP tears failing nonoperative management, arthroscopic SLAP repair is preferred to restore anatomy. In older patients, biceps tenodesis is typically preferred.

Question 56

A 30-year-old competitive tennis player complains of posterior shoulder pain and numbness over the lateral deltoid. Examination shows point tenderness at the posterior joint line and weakness in external rotation. Arteriogram reveals occlusion of the posterior humeral circumflex artery with shoulder abduction. What are the boundaries of the space involved?

Explanation

Quadrilateral space syndrome involves compression of the axillary nerve and posterior humeral circumflex artery. The boundaries are the teres minor (superior), teres major (inferior), long head of the triceps (medial), and humeral shaft (lateral).

Question 57

A 72-year-old woman is 6 months status-post an uncomplicated reverse total shoulder arthroplasty. She reports a sudden onset of lateral shoulder pain after lifting a heavy grocery bag, with a subsequent drop in active elevation. Radiographs show a displaced fracture of the acromion base. What factor is most associated with this complication?

Explanation

Acromial stress fractures after RTSA are associated with increased deltoid tension and excessive lateralization. The increased mechanical load on the acromion from the tensioned deltoid can lead to fatigue fractures, particularly at the base or spine.

Question 58

A 19-year-old male presents to the trauma bay following a high-speed motor vehicle collision. He complains of chest pain, shortness of breath, and dysphagia. His left shoulder is protracted, and there is a palpable depression at the left sternoclavicular joint. Which imaging study is the gold standard to evaluate this injury?

Explanation

This patient has a posterior sternoclavicular joint dislocation, a surgical emergency due to the proximity of the great vessels and trachea. A CT scan of the chest is the gold standard for diagnosis and evaluating mediastinal compromise.

Question 59

Which of the following is considered an absolute indication for operative fixation of an acute midshaft clavicle fracture?

Explanation

Open fractures, compromised skin (impending open), subclavian vessel injury, and symptomatic nonunion are absolute indications for clavicle fracture fixation. Displacement and shortening are relative indications based on patient factors.

Question 60

The "terrible triad of the shoulder" typically refers to an anterior shoulder dislocation accompanied by which two additional injuries?

Explanation

The classic "terrible triad of the shoulder" consists of an anterior shoulder dislocation, a rotator cuff tear, and a neurologic injury (often involving the brachial plexus or axillary nerve). This pattern usually occurs in older patients.

Question 61

A 25-year-old male weightlifter complains of superior shoulder pain exacerbated by the bench press and push-ups. He has localized tenderness over the AC joint. Radiographs show subchondral cystic changes and widening of the AC joint. What is the most appropriate initial management?

Explanation

The clinical presentation is consistent with distal clavicle osteolysis, a common finding in weightlifters. Initial treatment is nonoperative with activity modification and injections. Distal clavicle excision is reserved for refractory cases.

Question 62

A 24-year-old professional baseball pitcher presents with decreasing throwing velocity and shoulder pain in the late cocking phase. Examination reveals a loss of internal rotation of 25 degrees compared to the contralateral side, with a corresponding increase in external rotation. What is the primary anatomic structure responsible for this finding?

Explanation

Glenohumeral internal rotation deficit (GIRD) in throwers is primarily driven by contracture of the posterior capsule and the posterior band of the inferior glenohumeral ligament. Initial treatment involves sleeper stretches to restore internal rotation.

Question 63

During the physical examination of a patient with suspected rotator cuff pathology, the examiner places the patient's hand behind their back at the lumbar level and asks them to lift the hand away from the back. This test is primarily evaluating the integrity of which structure?

Explanation

The described maneuver is the "Gerber lift-off test," which isolates and tests the strength and integrity of the subscapularis muscle. The belly-press and bear-hug tests are also specific for subscapularis pathology.

Question 64

A 72-year-old female presents with pseudoparalysis of her right shoulder and severe pain. Imaging confirms a massive, retracted, irreparable rotator cuff tear involving the supraspinatus and infraspinatus, with advanced glenohumeral osteoarthritis. Her deltoid function is intact. Which of the following is the most appropriate surgical treatment?

Explanation

Reverse total shoulder arthroplasty (RTSA) is the gold standard for patients with cuff tear arthropathy and pseudoparalysis. It relies on an intact deltoid to elevate the arm, bypassing the deficient rotator cuff.

Question 65

According to the Walch classification of glenoid morphology in primary osteoarthritis, a B2 glenoid is best described by which of the following?

Explanation

The Walch B2 glenoid is characterized by a biconcave surface and posterior subluxation of the humeral head. It is a critical consideration in shoulder arthroplasty due to the need to address asymmetric posterior bone loss and retroversion.

Question 66

A 48-year-old female with poorly controlled type 1 diabetes presents with insidious onset of progressive shoulder stiffness and pain. Examination reveals a significant loss of both active and passive range of motion, particularly in external rotation. What is the most appropriate initial management?

Explanation

This patient has adhesive capsulitis, which is strongly associated with diabetes mellitus. Initial management consists of conservative measures, including a supervised physical therapy program and intra-articular corticosteroid injections to reduce inflammation.

Question 67

A 21-year-old collegiate rugby player with recurrent anterior shoulder instability undergoes a preoperative CT scan. The scan demonstrates a 28% anterior glenoid bone loss. Which of the following is the most appropriate surgical intervention?

Explanation

In young, high-demand athletes with recurrent anterior instability and critical glenoid bone loss (typically > 20-25%), a bony augmentation procedure like the Latarjet is indicated to restore glenohumeral stability. Soft tissue repair alone has an unacceptably high failure rate.

Question 68

In a reverse total shoulder arthroplasty, lateralization of the glenosphere provides which of the following biomechanical advantages compared to a traditional medialized design?

Explanation

Lateralization of the glenosphere in reverse total shoulder arthroplasty increases deltoid wrapping, improves external rotation, and significantly reduces the incidence of scapular notching compared to medialized designs.

Question 69

A 28-year-old male presents with shoulder pain and weakness after a posterior triangle neck biopsy. On physical examination, the scapula translates laterally and superiorly with attempted shoulder abduction. Injury to which of the following nerves is the most likely cause?

Explanation

Injury to the spinal accessory nerve denervates the trapezius, causing the scapula to wing laterally and superiorly. Conversely, long thoracic nerve injury denervates the serratus anterior, causing medial winging.

Question 70

According to recent quantitative anatomic studies, which of the following arteries provides the dominant blood supply to the native humeral head?

Explanation

While historically the anterior circumflex humeral artery was thought to be the primary supply, modern quantitative studies demonstrate that the posterior circumflex humeral artery provides the dominant blood supply to the humeral head.

Question 71

A 65-year-old male with primary osteoarthritis of the shoulder is planning to undergo an anatomic total shoulder arthroplasty. Preoperative CT scan demonstrates a biconcave glenoid with retroversion of 20 degrees and posterior subluxation of the humeral head. This glenoid morphology is best classified as:

Explanation

The Walch B2 glenoid is characterized by a biconcave articular surface with posterior wear, posterior humeral head subluxation, and increased retroversion. It is a critical consideration in anatomic TSA due to the high risk of early glenoid loosening.

Question 72

A 55-year-old laborer presents with an irreparable posterosuperior rotator cuff tear. He lacks active external rotation and forward elevation but has an intact subscapularis. Which of the following tendon transfers is most appropriate to restore external rotation?

Explanation

Lower trapezius and latissimus dorsi transfers are used for irreparable posterosuperior tears. The lower trapezius transfer more closely replicates the natural force vector of the infraspinatus and is increasingly favored for restoring external rotation.

Question 73

Which of the following is a specific component of the Instability Severity Index Score (ISIS), utilized to predict the risk of recurrent instability after an arthroscopic Bankart repair?

Explanation

The ISIS score includes age under 20 years, participation in competitive sports, participation in contact/forced overhead sports, anterior-posterior glenoid bone loss on AP radiograph, and a Hill-Sachs lesion visible on external rotation AP radiograph.

Question 74

A 32-year-old male weightlifter feels a pop in his anterior chest while bench pressing. Examination reveals a loss of the anterior axillary fold. If surgical repair is undertaken, the surgeon must recognize that the sternal head of the pectoralis major inserts in which orientation relative to the clavicular head?

Explanation

The pectoralis major tendon undergoes a 180-degree twist before insertion. Consequently, the sternal head inserts proximal and posterior to the clavicular head on the lateral lip of the bicipital groove.

Question 75

A 22-year-old collegiate baseball pitcher presents with vague posterior shoulder pain. Physical examination shows a Glenohumeral Internal Rotation Deficit (GIRD) of 25 degrees compared to the contralateral side. The primary anatomic structure responsible for this finding is:

Explanation

GIRD in throwing athletes is primarily caused by contracture and thickening of the posteroinferior capsule. This occurs as a maladaptive response to repetitive eccentric loading during the deceleration phase of throwing.

Question 76

During an anatomic reconstruction of a high-grade acromioclavicular joint separation, the surgeon targets the coracoclavicular ligaments. Which of the following statements regarding the native anatomy is correct?

Explanation

The conoid ligament is cone-shaped and inserts posteromedial to the trapezoid on the conoid tubercle. The trapezoid inserts anterolaterally and acts as the primary restraint to axial compression.

Question 77

A 50-year-old male presents with anterior shoulder pain after a fall. He has a positive "belly-press" test. Which of the following physical examination findings would also most likely be positive in this patient?

Explanation

The belly-press test and the bear hug test are both highly specific maneuvers for evaluating the integrity of the subscapularis tendon. Hornblower's sign and the external rotation lag sign evaluate the posterosuperior rotator cuff.

Question 78

A 42-year-old female presents with sudden onset of severe, unprovoked left shoulder pain that lasted for two weeks, followed by progressive weakness in shoulder elevation as the pain subsided. An MRI of the shoulder and cervical spine is unremarkable. What is the most likely diagnosis?

Explanation

Parsonage-Turner syndrome (idiopathic brachial neuritis) typically presents with acute, severe, unremitting shoulder pain. As the pain resolves over several weeks, the patient develops profound weakness and atrophy of the affected shoulder girdle musculature.

Question 79

A 29-year-old professional volleyball player presents with painless weakness of external rotation of the shoulder. Examination reveals isolated atrophy of the infraspinatus fossa. The supraspinatus strength and muscle bulk are normal. The most likely site of nerve compression is:

Explanation

Compression of the suprascapular nerve at the spinoglenoid notch presents with isolated weakness and atrophy of the infraspinatus. Compression more proximally at the suprascapular notch affects both the supraspinatus and infraspinatus.

Question 80

The superior transverse scapular ligament overlies the suprascapular notch. Which of the following correctly describes the anatomic relationship of the neurovascular structures at this level?

Explanation

At the suprascapular notch, the suprascapular artery passes over (superior to) the superior transverse scapular ligament, while the suprascapular nerve passes under (inferior to) the ligament. This is often remembered by the mnemonic "Army over, Navy under".

Question 81

A 17-year-old male sustains a posterior sternoclavicular joint dislocation during a rugby match. He presents with mild dyspnea and dysphagia. What is the most appropriate next step in management?

Explanation

Posterior sternoclavicular dislocations can fatally compress vital mediastinal structures. A CT scan is required to evaluate the position of the clavicle relative to the great vessels, and cardiothoracic surgery backup is mandated during reduction.

Question 82

A 45-year-old diabetic female presents with an acute exacerbation of excruciating shoulder pain. Radiographs reveal a large, amorphous calcific deposit in the supraspinatus tendon. During which phase of calcific tendinitis does the patient typically experience the most severe pain?

Explanation

Calcific tendinitis is most acutely painful during the resorptive phase. In this stage, vascular invasion and macrophage infiltration cause severe swelling and extreme inflammatory pain within the tendon.

Question 83

In a patient undergoing reverse total shoulder arthroplasty (RTSA), which of the following baseplate positioning strategies is most effective in minimizing the risk of postoperative scapular notching?

Explanation

Scapular notching is a frequent complication in reverse shoulder arthroplasty caused by mechanical impingement. Positioning the glenosphere with an inferior tilt and inferior overhang minimizes impingement of the humeral component against the scapular neck during adduction.

Question 84

A 22-year-old collegiate rugby player presents with recurrent anterior shoulder dislocations. Imaging reveals a 25% anterior glenoid bone loss defect. Which of the following is the most appropriate surgical intervention?

Explanation

In collision athletes with critical anterior glenoid bone loss (greater than 20-25%), isolated soft tissue repairs have unacceptably high failure rates. The Latarjet procedure (coracoid transfer) is required to restore the articular arc and provide a triple blocking effect.

Question 85

A 48-year-old heavy laborer presents with deep anterior shoulder pain. MRI confirms an isolated Type II SLAP tear. Nonoperative management has failed after 6 months. What is the most appropriate surgical management?

Explanation

For patients older than 40 with symptomatic Type II SLAP tears, biceps tenodesis is preferred over SLAP repair. This approach avoids the high rates of postoperative stiffness, persistent pain, and revision surgery associated with SLAP repairs in older patients.

Question 86

A 35-year-old elite volleyball player complains of vague posterior shoulder pain and isolated weakness in external rotation. Examination shows atrophy of the infraspinatus with a normal supraspinatus. Where is the most likely location of nerve entrapment?

Explanation

Entrapment of the suprascapular nerve at the spinoglenoid notch, often by a paralabral cyst, results in isolated denervation of the infraspinatus. Entrapment further proximal at the suprascapular notch would affect both the supraspinatus and infraspinatus muscles.

Question 87

A patient presents with vague posterior shoulder pain and isolated atrophy of the teres minor. An MRI demonstrates quadrilateral space syndrome. Which of the following correctly defines the borders of the quadrilateral space?

Explanation

The quadrilateral space is bounded superiorly by the teres minor, inferiorly by the teres major, medially by the long head of the triceps, and laterally by the humeral shaft. It transmits the axillary nerve and the posterior humeral circumflex artery.

Question 88

During arthroscopy, a surgeon identifies a complete full-thickness tear of the upper border of the subscapularis tendon. This pathology is most frequently associated with the disruption and subsequent subluxation or dislocation of which of the following structures?

Explanation

Complete tears of the upper border of the subscapularis frequently disrupt the medial biceps sling, which is composed of the coracohumeral and superior glenohumeral ligaments. This leads to medial subluxation or dislocation of the long head of the biceps tendon.

Question 89

In a patient undergoing anatomic total shoulder arthroplasty (TSA), failure to correct excessive posterior glenoid retroversion (B2 glenoid) is most likely to result in which of the following mechanisms of failure?

Explanation

Uncorrected posterior glenoid retroversion and posterior humeral head subluxation lead to eccentric loading on the posterior aspect of the glenoid component. This causes a "rocking horse" phenomenon, resulting in early catastrophic glenoid loosening.

Question 90

A 55-year-old patient with type 2 diabetes presents with a profound, painful loss of active and passive shoulder external rotation with the arm at the side. In primary adhesive capsulitis, which structures exhibit the most significant fibroblastic proliferation and contracture?

Explanation

The primary histopathology of adhesive capsulitis involves dense fibroblastic proliferation and thickening of the joint capsule. This is most prominent at the rotator interval and coracohumeral ligament, directly restricting external rotation with the arm at the side.

Question 91

A 28-year-old bodybuilder experiences a sudden "pop" in his anterior axilla while performing a heavy bench press. Examination reveals loss of the normal anterior axillary fold. Which of the following best describes the most common anatomical location of a pectoralis major rupture?

Explanation

The vast majority of pectoralis major ruptures occur during eccentric loading (like heavy bench pressing) and involve the sternal head at its tendinous insertion on the humerus. Surgical repair is indicated in active patients to restore adduction and internal rotation strength.

100 High-Yield Orthopedic MCQs: Shoulder & Elbow | Mock Exam 251

Orthopedic Shoulder 2026 MCQs: Board Review Questions & Answers (Part 1)

Key Takeaway

Orthopedic Shoulder 2026 MCQs: Board Review Questions & Answers (Part 1)

Chapter Index