Orthopedic Shoulder Board Review 2026: MCQs Part 2

Question 1

A 37-year-old electrician is diagnosed with a frozen shoulder after sustaining an electrical injury at work 2 weeks ago. Examination reveals that he cannot actively or passively externally rotate or abduct the arm. The glenohumeral joint and scapula move in a 1:1 ratio. Radiographs are shown in Figures 15a and 15b. The best course of action should be

Explanation

15b The patient's history, examination, and radiographs are classic for locked posterior dislocation of the glenohumeral joint. Posterior dislocation of the shoulder remains the most commonly missed dislocation of a major joint. Up to 80% are missed on initial presentation. The primary cause for failure to accurately diagnose this injury is inadequate radiographic evaluation. The typical presentation is a shoulder locked in internal rotation with loss of abduction. An axillary view not only will make the definitive diagnosis but will help assess the size of the articular surface defect and help plan treatment. This view can be done expediently as part of every trauma series. The AP view is suspicious for a posteriorly dislocated humerus with loss of the humeral neck profile, a vacant glenoid sign, and an anterior humeral head compression fracture (reverse Hill-Sachs lesion). Hawkins RJ, Neer CS II, Pianta RM, Mendoza FX: Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1987;69:9-18. Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosement, IL, American Academy of Orthopaedic Surgeons, 1997, pp 181-189.

Question 2

An 80-year-old man has had increasing shoulder pain for the past 4 months. He reports that it began with soreness and stiffness after chopping some wood. A coronal MRI scan is shown in Figure 16. Initial management should consist of

Explanation

The MRI scan shows a massive tear of the supraspinatus tendon with medial retraction to the level of the glenoid. This is most likely an attritional tear with a high risk of failure of the repair. The preferred treatment is nonsurgical management for pain and stiffness. Acromioplasty and coracoacromial ligament release in this setting are controversial, as they can result in the devastating complication of anterosuperior subluxation of the humerus. Rockwood CA Jr, Williams GR Jr, Burkhead WZ Jr: Debridement of degenerative, irreparable lesions of the rotator cuff. J Bone Joint Surg Am 1995;77:857-866.

Question 3

Figure 17 shows the radiograph of a 25-year-old professional football player who has superior shoulder pain that prevents him from sports participation. History reveals that he sustained a shoulder injury that was treated with closed reduction and temporary pinning 3 years ago. The best course of action should be

Explanation

The radiograph shows a complete acromioclavicular separation. Because the patient is a professional athlete who is unable to participate, surgery is indicated. Chronic separations, especially those with previous trauma from joint pinning, should be treated with resection of the distal clavicle and stabilization to the coracoid. Some type of biologic reconstruction of the coracoclavicular ligaments is generally recommended. Open repair of the ligaments is generally not possible in such a delayed fashion. Screw fixation alone will not provide a lasting solution as the screws usually need to be removed, leaving no fixation in place. Reconstruction using the coracoacromial ligament is generally recommended with coracoclavicular fixation to protect the repair while it heals. Nuber GW, Bowen MK: Disorders of the acromioclavicular joint: Pathophysiology, diagnosis and management, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams and Wilkins, 1999.

Question 4

A 54-year-old man undergoes total shoulder arthroplasty for osteoarthritis. Despite compliance with an early passive range-of-motion exercise program, he does not regain more than 90 degrees of elevation, 10 degrees of external rotation, and has internal rotation to the fifth lumbar vertebra. At 6 months, his motion fails to improve. Radiographs are shown in Figures 18a and 18b. What is the best course of action?

Explanation

18b The patient has a global loss of motion that has failed to improve with 6 months of nonsurgical treatment; because he has reached a plateau, further nonsurgical management will likely be ineffective. Revision in the form of an open release is indicated to lyse intra- and extra-articular adhesions; subscapularis lengthening may be done concurrently as needed. Revising to a smaller head can be considered if adequate motion is not achieved. The radiographs reveal an adequate neck cut with appropriate seating of the component. Removing the glenoid component will decrease capsular tension but will probably increase pain because of the lack of glenoid resurfacing. Increasing humeral retroversion will not improve motion. Cuomo F, Checroun A: Avoiding pitfalls and complication in total shoulder arthroplasty. Orthop Clin North Am 1998;29:507-518.

Question 5

A 47-year-old patient has had persistent pain and weakness after undergoing a reamed intramedullary nailing for a midshaft humerus fracture 8 months ago. There is no evidence of infection. Radiographs are shown in Figures 19a and 19b. Management should consist of

Explanation

19b Compression plating remains the treatment of choice for most established humeral nonunions. Autograft is felt to be superior to allograft. Electrical stimulation has not been found to improve healing rates in patients with nonunion after intramedullary nailing. Retrograde nailing with flexible nails gives inadequate rotational control to promote healing in this patient. Adding cancellous graft alone will not stabilize the nonunion site. Dynamic locking has been successful only in the lower extremity because the bone can be loaded axially. McKee MD, Miranda MA, Riemer BL, et al: Management of humeral nonunion after the failure of locking intramedullary nails. J Orthop Trauma 1996;10:492-499.

Question 6

An 18-year-old man sustained closed humeral shaft and forearm fractures of his dominant arm in a motor vehicle accident. Neurovascular examination is intact, and his condition is stable. The best course of action for management of the injuries should be

Explanation

Fractures above and below the elbow constitute floating elbow injuries and are best treated with internal fixation to allow early range of motion and to prevent elbow stiffness. Use of a long arm cast would promote elbow stiffness. External fixation is indicated primarily for open injuries. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.

Question 7

A 32-year-old woman has had pain and a visibly growing mass in the shoulder for 3 years but denies any history of trauma. Examination reveals a swollen, boggy shoulder mass. The AP radiograph and MRI scan are shown in Figures 20a and 20b. Figures 20c through 20e show a portion of the excised mass and the photomicrographs of the biopsy specimen. What is the most likely diagnosis?

Explanation

20b 20c 20d 20e The radiographic findings are classic for synovial chondromatosis because of the small calcified opacities within the joint surrounding the synovium. The histologic findings show cartilaginous foci of metaplasia, which may be markedly cellular. However, unlike low-grade chondrosarcoma, it lacks cellular and nuclear pleomorphism. Murphy FP, Dahlin DC, Sullivan CR: Articular synovial chondromatosis. J Bone Joint Surg Am 1982;44:77-86.

Question 8

What is the most important factor regarding the risk of recurrent instability in a patient with an acute anterior dislocation of the shoulder?

Explanation

The recurrence rate of anterior dislocation of the shoulder after the first episode in athletes younger than age 20 years is thought to be as high as 90%, making surgery after the initial episode a consideration. The rate drops from 50% to 75% in the 20- to 25-year age group and down to 15% in patients older than age 40 years. An excellent prospective study of 257 patients in Sweden showed that there was no difference in those who did or did not complete 3 weeks of immobilization. The study also showed variability among different age groups in the importance of athletic participation; athletes in the 12- to 22-year age group had a higher recurrence rate, whereas the more sedentary patients in the 23- to 29-year age group had a higher rate. Hovelius L: The natural history of primary anterior dislocation of the shoulder in the young. J Orthop Sci 1999;4:307-317.

Question 9

A 25-year-old man injured his dominant shoulder after falling on his outstretched arm 4 months ago. Examination reveals that he cannot lift his arm above 90 degrees, and he has pronounced medial scapular winging. Management should consist of

Explanation

Serratus anterior palsy or long thoracic nerve palsy is usually caused by traction injury to the nerve, blunt injury, or iatrogenic injury. The palsy results in winging of the scapula and medial rotation of the inferior pole of the scapula. A patient with this injury will usually recover in 12 to 18 months. Initial treatment should include observation and shoulder strengthening exercises. Nerve exploration with repair has not proven beneficial in changing the outcome. Many orthopaedic surgeons favor using a split pectoralis major transfer for symptomatic patients. Electrodiagnostic studies are helpful in confirming the diagnosis. Post M: Pectoralis major transfer for winging of the scapula. J Shoulder Elbow Surg 1995;4:1-9.

Question 10

Treatment of adhesive capsulitis has a high failure rate when the underlying cause is

Explanation

Diabetes mellitus has been associated with resistant cases of adhesive capsulitis. With other causes of onset, adhesive capsulitis frequently responds to nonsurgical management such as stretching exercises or, when this fails, manipulation under anesthesia and/or arthroscopic release. Manipulation is rarely successful for the treatment of adhesive capsulitis associated with diabetes mellitus, and arthroscopic release may be preferred. Fisher L, Kurtz A, Shipley M: Association between cheiroarthropathy and frozen shoulder in patients with insulin-dependent diabetes mellitus. Br J Rheumatol 1986;25:141-146. Janda DH, Hawkins RJ: Shoulder manipulation in patients with adhesive capsulitis and diabetes mellitus: A clinical note. J Shoulder Elbow Surg 1993;2:36-38.

Question 11

Figure 21 shows the AP radiograph of a 41-year-old patient who sustained a closed bicolumnar fracture of the distal humerus that resulted in a painful nonunion. What is the best initial construct for rigid stabilization of this fracture pattern?

Explanation

The dual plate fixation construct is significantly stronger than single plate or "Y" plate fixation. Two-plate constructs at right angles, the ulnar plate medially and the lateral plate posteriorly, would appear to be biomechanically optimal. This approach usually is feasible at the time of surgery. Clinically, dual 3.5-mm reconstruction or dynamic compression plates are superior to one third tubular plate fixation. Supplementary external fixation is not considered a better treatment option. Failure of fixation and nonunion are often the result of inadequate fixation and osteoporosis. Helfet DL, Hotchkiss RN: Internal fixation of the distal humerus: A biomechanical comparison of methods. J Orthop Trauma 1990;4:260-264.

Question 12

Figure 22 shows the radiographs of a 16-year-old boy who injured his elbow in a fall 1 year ago. Although he has no pain, he reports restricted forearm rotation and elbow flexion. What is the most likely diagnosis?

Explanation

Congenital dislocation of the radial head is often confused with posttraumatic dislocation. The distinguishing feature here is the dome-shaped radial head. Some patients with congenital anomalies fail to recognize their limitations until an injury occurs. Soft-tissue contractures do not cause radial head dislocation nor do they usually cause this pattern of motion restriction (mainly flexion and rotation without significant loss of extension). There is no deformity of the ulna to suggest an old Monteggia lesion. Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, PA, WB Saunders, 1993, p 196.

Question 13

A 55-year-old man has had progressive right shoulder pain for the past 2 years. Examination reveals active elevation to 120 degrees, external rotation to 20 degrees, and internal rotation to the sacrum. AP and axillary radiographs are shown in Figures 23a and 23b. Which of the following procedures would result in the most predictable long-term pain relief?

Explanation

23b Total shoulder arthroplasty yields excellent pain relief and function in patients with osteoarthritis. It is favored over humeral arthroplasty, especially when there is asymmetric posterior glenoid wear and posterior humeral subluxation as shown on the axillary radiograph. Arthroscopic debridement of the glenohumeral joint may be helpful in delaying the need for arthroplasty when the arthritic changes are mild to moderate but is not indicated for advanced osteoarthritis. Cofield RH, Frankle MA, Zuckerman JD: Humeral head replacement for glenohumeral arthritis. Semin Arthroplasty 1995;6:214-221. Levine WN, Djurasovic M, Glasson JM, Pollock RG, Flatow EL, Bigliani LU: Hemiarthroplasty for glenohumeral osteoarthritis: Results correlated to degree of glenoid wear. J Shoulder Elbow Surg 1997;6:449-454.

Question 14

A 20-year-old professional baseball pitcher has had a 3-year history of increased aching in his shoulder that is associated with pitching, and he is now seeking a second opinion. Nonsurgical management consisting of rest, anti-inflammatory drugs, ice, heat, and cortisone injections has failed to provide relief. A previous work-up that included radiographs and gadolinium-enhanced MRI arthrography was negative. Results of an arteriogram suggest quadrilateral space syndrome. Assuming that this is the correct diagnosis, what nerve needs to be decompressed?

Explanation

Quadrilateral space syndrome is a rare condition and is the result of compression of the contents of the quadrilateral space. The contents of the quadrilateral space include the posterior circumflex vessels and the axillary nerve. Cahill BR, Palmer RE: Quadrilateral space syndrome. J Hand Surg 1983;8:65-69.

Question 15

A right-handed 24-year-old woman underwent an arthroscopic Bankart repair for recurrent anterior dislocations 9 months ago. Despite extensive physical therapy for 8 months, the patient has very limited range of motion (elevation to 130 degrees and external rotation to 10 degrees with the arm at the side). Shoulder radiographs are normal. The next step in management should consist of

Explanation

Arthroscopic capsular release is an effective means of treating stiffness that is the result of capsular contractures, such as in the case of a tight Bankart repair. Open release allows lengthening of a surgically shortened subscapularis, such as after a tight Putti-Platt repair. Additional physical therapy is unlikely to be effective because 8 months of treatment has failed to result in improvement. Accepting this degree of asymptomatic limited motion is not advisable because of the functional limitations for the patient and the increased risk of postoperative degenerative arthritis. Warner JJ, Allen AA, Marks PH, Wong P: Arthroscopic release of postoperative capsular contracture of the shoulder. J Bone Joint Surg Am 1997;79:1151-1158.

Question 16

A patient with deficient anteroinferior bone stock undergoes a Latarjet procedure that transfers a portion of the coracoid to the glenoid rim and secures it with two screws. After surgery, the patient reports numbness on the anterolateral forearm. To verify the diagnosis, what muscle should be tested for strength?

Explanation

A Latarjet procedure is similar to a Bristow procedure, but with the Latarjet procedure a larger portion of the coracoid is transferred to the scapular neck at the anteroinferior glenoid. As in a Bristow procedure, if the fragment is pulled or twisted during the dissection or during fixation, the musculocutaneous nerve can be injured. With loss of biceps function, elbow flexion and forearm supination will be weaker. Ho E, Cofield RH, Balm MR, Hattrup SJ, Rowland CM: Neurologic complications of surgery for anterior shoulder instability. J Shoulder Elbow Surg 1999;8:266-270. Boardman ND 3rd, Cofield RH: Neurologic complications of shoulder surgery. Clin Orthop 1999;368:44-53.

Question 17

A 34-year-old woman has had painful snapping and popping in the elbow since falling while in-line skating 6 months ago. The popping also occurs when she pushes off with her hands to rise from a seated position. Initial radiographs were normal, and she was told that she had sprained her elbow. Examination reveals few findings except that she is very apprehensive when the forearm is forcefully supinated with the elbow extended or partially flexed. A radiograph taken in that position is shown in Figure 24. Treatment should consist of

Explanation

The radiograph reveals posterolateral rotatory subluxation of the radiohumeral and ulnohumeral joints. The space between the ulna and trochlea is enlarged, particularly posteriorly at the olecranon. These findings are diagnostic of posterolateral rotatory instability, which causes recurrent subluxation and reduction as the elbow is flexed from an extended and supinated position with valgus load. The posterolateral rotatory instability apprehension test was performed on this patient and the result was positive. The lateral pivot-shift test causes a clunk as the elbow reduces but is more difficult to perform, even under general anesthesia. The patient does not have isolated subluxation of the radial head, although these findings can be mistakenly diagnosed as such. The radial head is normally shaped and does not represent a congenital dislocation. There are no findings here to suggest osteochondritis dissecans or loose bodies. O'Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440-446. Burgess RC, Sprague HH: Post-traumatic posterior radial head subluxation: Two case reports. Clin Orthop 1984;186:192-194.

Question 18

A 49-year-old woman noted pain in her right axilla 1 day after moving heavy furniture. Two weeks later, she now reports persistent numbness and paresthesias along the inner aspect of her upper arm radiating into the ulnar digits. Examination reveals full shoulder motion, tenderness over the first rib, and a decreased radial pulse with the shoulder placed overhead. What is the most likely diagnosis?

Explanation

Thoracic outlet syndrome is thought to be caused by compression of the neurovascular supply to the upper limb in the supraclavicular and axillary regions of the shoulder. While typically progressive in onset, thoracic outlet syndrome may develop after acute injury. Injury or weakness of the scapular muscles, especially the trapezius, may result in descent of the scapula and cause compression of the thoracic outlet. In general, most symptoms are the result of neural compression. Typical symptoms include pain in the neck or shoulder and numbness or tingling that predominantly involves the ulnar side of the arm and hand. Exacerbation of these symptoms is typical when the arm is abducted. Initial management should consist of postural exercises aimed at restoring proper scapular stability. Severe recalcitrant symptoms may warrant surgical decompression. Leffert RD: Thoracic outlet syndrome. J Am Acad Orthop Surg 1994;2:317-325.

Question 19

A patient has had a locked posterior dislocation of the shoulder for the past 6 months. After undergoing total shoulder arthroplasty that includes adequate anterior releases and posterior capsulorrhaphy, the patient still exhibits posterior instability intraoperatively. The postoperative rehabilitation regimen should include

Explanation

Achieving stability in chronic locked posterior dislocations of the shoulder remains a difficult challenge. Intraoperative measures include decreased humeral retroversion, anterior releases, and posterior capsular tightening. Postoperative rehabilitation is of equal importance. Immobilization in an external rotation brace (10 degrees to 15 degrees) with the arm at the side for 4 to 6 weeks is recommended to decrease tension in the posterior capsule. When passive range-of-motion exercises are instituted, they should be performed in the plane of the scapula to avoid stress posteriorly. Internal rotation and supine elevation should be avoided for similar reasons. Hawkins RJ, Neer CS II, Pianta RM, Mendoza FX: Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1987;69:9-18.

Question 20

Which of the following factors is associated with failure of arthroscopic excision of the distal clavicle?

Explanation

Uneven resection of bone, typically leaving a retained posterolateral corner of the distal clavicle, can lead to failure of arthroscopic distal clavicle excision. The amount of bone resected, the gender of the patient, or the diagnosis (osteoarthritis versus osteolysis) does not appear to affect the results.

Question 21

Anterior subluxation in a throwing athlete is most commonly the result of

Explanation

Subtle anterior subluxation in the throwing athlete most frequently results from excessive capsular laxity because of repetitive microtrauma. Avulsion of the inferior glenohumeral ligament from the glenoid, or more rarely from the humerus, occurs with macrotrauma. A large Hill-Sachs lesion and a glenoid rim fracture also may result from a traumatic anterior dislocation. Kvitne RS, Jobe FW: The diagnosis and treatment of anterior instability in the throwing athlete. Clin Orthop 1993;291:107-123.

Question 22

What is the most significant prognostic factor in nontraumatic osteonecrosis of the humeral head?

Explanation

Use of systemic steroids has been implicated in the development of nontraumatic osteonecrosis of the humeral head. Staging of the disease is most relevant to prognosis and treatment. Cruess has described a widely accepted staging system. Several authors have shown that patients who have a lower stage of disease (ie, stage I or II) have a much less likely chance of progression compared with those who are in the later stages (IV and V). Cruess RL: Osteonecrosis of bone: Current concepts as to etiology and pathogenesis. Clin Orthop 1986;208:30-39. Cruess RL: Steroid-induced avascular necrosis of the humeral head: Natural history and management. J Bone Joint Surg Br 1976;58:313-317. Rutherford CS, Cofield RH: Osteonecrosis of the shoulder. Orthop Trans 1987;11:239.

Question 23

A 43-year-old former professional hockey player reports severe pain in his chest after being checked from the side in a pick-up hockey game. An MRI scan and plain radiographs are shown in Figures 25a through 25c. What is the most likely diagnosis?

Explanation

25b 25c Anterior dislocation is the most common type of sternoclavicular dislocation. The medial end of the clavicle is displaced anterior or anterosuperior to the anterior margin of the sternum. In a study by Omer, 31% of athletic injuries have been known to cause a dislocation of the sternoclavicular joint. The serendipity view can show this dislocation, as will CT of the chest. This view requires the x-ray beam to be aimed at the manubrium with 40 degrees of cephalic tilt. An anterior sternoclavicular joint dislocation will appear superiorly displaced, while a posterior sternoclavicular joint dislocation is inferiorly displaced on the serendipity view. Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1998, vol 1, pp 566-572.

Question 24

Which of the following is considered a contraindication to functional bracing for the treatment of humeral shaft fractures?

Explanation

Most closed humeral shaft fractures and fractures caused by a low-velocity hand gun can be managed nonsurgically with closed reduction and application of a coaptation splint followed by a functional brace. Contraindications to use of the functional brace include: 1) massive soft-tissue or bone loss; 2) an unreliable or noncompliant patient; and 3) an inability to maintain acceptable fracture alignment of up to 20 degrees of anterior or posterior angulation, 30 degrees of varus or valgus angulation, and greater than 3 cm of shortening. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286. Pollock FH, Drake D, Bovill EG, Day L, Trafton PG: Treatment of radial neuropathy associated with fractures of the humerus. J Bone Joint Surg Am 1981;63:239-243.

Question 25

A 20-year-old man with fascioscapulohumeral dystrophy has severe scapular winging of both shoulders. He can no longer abduct above 80 degrees, and it affects his activities of daily living. A clinical photograph is shown in Figure 26. Definitive management should consist of

Explanation

The patient's history is typical of patients with severe fascioscapulohumeral dystrophy. The scapular winging can be so pronounced that there is significant loss of function of the upper extremity. The surgical options include transfer of the pectoralis major muscle with a tendon graft or scapulothoracic fusion. The latter is a technically demanding procedure but can provide a very stable platform for the upper extremity. Most patients will see increased elevation of the extremity once the scapula is stabilized. Pectoralis minor transfer has not been described and would not be effective. 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 65-year-old woman with cuff tear arthropathy undergoes a reverse total shoulder arthroplasty. During templating and component positioning, which of the following modifications minimizes the risk of scapular notching?

Explanation

Inferior placement and inferior tilt of the glenosphere, along with lateralization, decrease the risk of scapular notching in reverse total shoulder arthroplasty by improving clearance between the humeral component and the inferior scapular neck.

Question 27

A 22-year-old collegiate baseball pitcher presents with vague posterior shoulder pain and a significant decrease in throwing velocity. Physical examination reveals a 25-degree deficit in glenohumeral internal rotation compared to the contralateral side. What is the most likely primary pathophysiology for this range of motion deficit?

Explanation

Glenohumeral internal rotation deficit (GIRD) in overhead athletes is typically caused by a contracture of the posterior band of the inferior glenohumeral ligament (IGHL) and posterior capsule, leading to a posterosuperior shift of the humeral head during the cocking phase.

Question 28

A 45-year-old manual laborer presents with persistent anterior shoulder pain. MRI confirms a type II superior labrum anterior to posterior (SLAP) tear. Nonoperative management has failed after 6 months. What is the best next step in management?

Explanation

In patients older than 40 years, biceps tenodesis yields superior functional outcomes, higher satisfaction, and lower revision rates compared to primary SLAP repair for type II SLAP lesions.

Question 29

A 28-year-old weightlifter feels a "pop" and tearing sensation in his anterior chest wall while performing a heavy bench press. Examination reveals loss of the anterior axillary fold and weakness in internal rotation. Which of the following is true regarding this injury?

Explanation

Pectoralis major ruptures typically occur during eccentric contraction, such as a bench press, and most commonly involve avulsion of the sternocostal head from its humeral insertion. Surgical repair is recommended in active patients to restore strength.

Question 30

A 35-year-old male presents with isolated weakness in external rotation of his right shoulder. He has no pain. Examination reveals marked atrophy of the infraspinatus fossa but a normal supraspinatus fossa. The most likely cause is compression of the suprascapular nerve at which of the following locations?

Explanation

Entrapment of the suprascapular nerve at the spinoglenoid notch affects only the infraspinatus muscle. Entrapment at the suprascapular notch would affect both the supraspinatus and infraspinatus muscles.

Question 31

A 20-year-old rugby player has recurrent anterior shoulder instability. CT scan shows 25% anterior glenoid bone loss. Which of the following procedures is most appropriate to prevent recurrent dislocation?

Explanation

For critical glenoid bone loss (>20-25%), an arthroscopic Bankart repair has an unacceptably high failure rate. A coracoid transfer (Latarjet procedure) is the preferred treatment to restore anterior glenoid tracking and provide a dynamic sling effect.

Question 32

A 72-year-old man presents with chronic shoulder pain and inability to actively elevate his arm above 40 degrees. Passive elevation is 150 degrees. Radiographs show superior migration of the humeral head with an acromiohumeral interval of 3 mm. The deltoid is functioning normally. What is the most appropriate surgical treatment?

Explanation

Reverse total shoulder arthroplasty is the treatment of choice for patients with rotator cuff tear arthropathy and pseudoparalysis, provided the deltoid is intact to power the reverse construct.

Question 33

Which of the following physical examination findings is most specific for an isolated tear of the subscapularis tendon?

Explanation

The lift-off test and belly-press test specifically isolate the subscapularis muscle. The lift-off test is highly specific for evaluating the integrity of the lower subscapularis tendon.

Question 34

A 65-year-old male presents with a chronic massive rotator cuff tear and pseudoparalysis (active elevation less than 90 degrees). Physical examination reveals an intact deltoid, and radiographs demonstrate no evidence of glenohumeral osteoarthritis. What is the most appropriate surgical management?

Explanation

Reverse total shoulder arthroplasty is the treatment of choice for massive, irreparable rotator cuff tears accompanied by pseudoparalysis. Superior capsular reconstruction and tendon transfers require intact active elevation and are contraindicated in the setting of pseudoparalysis.

Question 35

A 24-year-old competitive tennis player presents with right shoulder pain and weakness, particularly when serving. On examination, there is prominent medial winging of the scapula that worsens when he pushes against a wall. Which of the following nerves is most likely injured, and what is the corresponding muscle?

Explanation

Medial winging of the scapula is classically caused by a long thoracic nerve palsy leading to serratus anterior weakness. Spinal accessory nerve palsy causes lateral winging due to trapezius dysfunction.

Question 36

A 45-year-old manual laborer presents with deep, aching anterior shoulder pain. MRI shows a Type II SLAP lesion with no other pathology. He has failed 6 months of conservative management. What is the most appropriate surgical treatment?

Explanation

In patients over age 40 with symptomatic Type II SLAP tears, biceps tenodesis provides superior clinical outcomes and lower revision rates compared to arthroscopic SLAP repair. SLAP repair in this age group is associated with significant postoperative stiffness.

Question 37

A 76-year-old woman sustains a displaced 4-part proximal humerus fracture. She has a history of severe osteoporosis. A decision is made to proceed with reverse total shoulder arthroplasty (rTSA). Healing of the tuberosities to the humeral shaft in rTSA is primarily associated with:

Explanation

In rTSA for proximal humerus fractures, anatomic tuberosity healing significantly improves clinical outcomes. Specifically, it enhances active external and internal rotation by restoring the rotator cuff force couples.

Question 38

A 22-year-old collegiate baseball pitcher presents with posterior shoulder pain during the late cocking phase of throwing. He has a 20-degree loss of internal rotation (GIRD) compared to the contralateral side. MRI arthrogram reveals articular-sided, partial-thickness tears of the posterior supraspinatus and anterior infraspinatus. What is the primary underlying pathophysiology?

Explanation

Internal impingement in overhead athletes occurs due to excessive external rotation and abduction (late cocking phase). This causes the posterosuperior rotator cuff to impinge between the greater tuberosity and the posterosuperior glenoid labrum.

Question 39

A 32-year-old weightlifter feels a "pop" in his anterior axilla while performing a heavy bench press. Examination reveals an asymmetric axillary fold and weakness in internal rotation. MRI confirms a complete rupture of the pectoralis major tendon at its humeral insertion. Which of the following statements regarding this injury is true?

Explanation

Pectoralis major ruptures typically occur during eccentric contraction, such as a bench press. The sternal head is under maximal tension when the arm is extended and externally rotated, making it the most frequently torn component.

Question 40

A 60-year-old man with primary glenohumeral osteoarthritis presents for total shoulder arthroplasty. A preoperative CT scan reveals a Walch B2 glenoid with 20 degrees of retroversion and posterior subluxation of the humeral head. Which of the following strategies is most appropriate for managing the glenoid deformity during anatomic TSA?

Explanation

For Walch B2 glenoids, asymmetric anterior reaming can safely correct up to 10-15 degrees of retroversion. Excessive reaming must be avoided as it violates subchondral bone and decreases glenoid vault volume, increasing the risk of component loosening.

Question 41

A 55-year-old man presents with anterior shoulder pain and increased external rotation after a fall. Examination demonstrates a positive bear-hug test. MRI shows a complete avulsion of the upper two-thirds of the subscapularis tendon with retraction to the glenoid rim. According to the Lafosse classification, what type of tear is this?

Explanation

In the Lafosse classification, Type III is a complete tear of the upper two-thirds of the subscapularis with retraction to the glenoid rim. Type IV is a complete tear with retraction to the glenoid, and Type V retracts medial to the glenoid.

Question 42

A 29-year-old professional volleyball player presents with vague posterior shoulder pain and weakness in external rotation. Examination reveals profound atrophy of the infraspinatus fossa, while the supraspinatus fossa is preserved. MRI is most likely to show a paralabral cyst at which of the following locations?

Explanation

Compression of the suprascapular nerve at the spinoglenoid notch selectively denervates the infraspinatus, leading to isolated external rotation weakness. Compression at the suprascapular notch affects both the supraspinatus and infraspinatus.

Question 43

A 22-year-old rugby player has recurrent anterior shoulder instability. A 3D CT reconstruction shows 25% anterior glenoid bone loss. What is the most appropriate surgical management?

Explanation

The Latarjet procedure (coracoid transfer) is indicated for patients with recurrent anterior instability and critical anterior glenoid bone loss (>20-25%). Arthroscopic Bankart repair in this setting is associated with unacceptably high recurrence rates.

Question 44

A 35-year-old recreational tennis player presents with vague posterior shoulder pain and paresthesias over the lateral deltoid. An MRI of the shoulder reveals isolated atrophy and fatty infiltration of the teres minor muscle. Which of the following structures is most likely compressed?

Explanation

Quadrilateral space syndrome involves compression of the axillary nerve and posterior circumflex humeral artery. It classically presents with deltoid or teres minor weakness and is most specifically seen as isolated teres minor fatty infiltration on MRI.

Question 45

A 25-year-old male undergoes a Latarjet procedure for recurrent anterior shoulder instability. Postoperatively, he exhibits profound weakness in elbow flexion and decreased sensation over the lateral forearm. Which of the following nerves was most likely injured during the procedure?

Explanation

The musculocutaneous nerve courses an average of 3-5 cm distal to the tip of the coracoid process. Retraction of the conjoined tendon during the Latarjet procedure places this nerve at significant risk.

Question 46

A 28-year-old cyclist falls directly onto his shoulder. Radiographs reveal 100% superior displacement of the clavicle relative to the acromion, with the clavicle displaced posteriorly into the trapezius fascia on the axillary lateral view. What is the Rockwood classification and optimal management for this injury?

Explanation

A Rockwood Type IV AC joint separation involves posterior displacement of the distal clavicle into or through the trapezius fascia. Because it is highly symptomatic and functionally limiting, it generally requires surgical reduction and stabilization.

Question 47

A 19-year-old male is tackled during a rugby match and sustains a posterior sternoclavicular joint dislocation. He complains of shortness of breath and difficulty swallowing. Closed reduction in the operating room is planned. Which of the following surgical subspecialties MUST be immediately available during this procedure?

Explanation

Posterior sternoclavicular dislocations can compress or injure critical mediastinal structures, including the trachea, esophagus, and great vessels. Cardiothoracic or vascular surgery must be on standby during reduction in case of catastrophic vascular injury.

Question 48

A 55-year-old manual laborer presents with a massive, irreparable posterosuperior rotator cuff tear. He has an intact subscapularis and active forward elevation to 130 degrees, but profound weakness in external rotation resulting in a positive hornblower's sign. A latissimus dorsi tendon transfer is planned. The latissimus dorsi muscle is primarily innervated by which of the following nerves?

Explanation

The latissimus dorsi is innervated by the thoracodorsal nerve (C6-C8). It is transferred to the greater tuberosity to substitute for an irreparable posterosuperior rotator cuff tear, converting its function to external rotation and humeral head depression.

Question 49

When placing the glenoid baseplate during a reverse total shoulder arthroplasty, the optimal position to minimize scapular notching and maximize range of motion is:

Explanation

Inferior positioning and inferior tilt of the glenosphere (baseplate) are crucial in reverse total shoulder arthroplasty. This position minimizes the incidence of inferior scapular notching and appropriately tensions the deltoid.

Question 50

During an arthroscopic Bankart repair for a patient with a 15% anterior glenoid bone loss and a large, engaging Hill-Sachs lesion, a remplissage procedure is performed. This procedure involves tenodesis of which of the following structures into the humeral head defect?

Explanation

The remplissage procedure addresses an engaging Hill-Sachs lesion by tethering the infraspinatus tendon and the posterior capsule into the bony defect. This converts the intra-articular defect to an extra-articular one.

Question 51

A 52-year-old woman with type 1 diabetes presents with severe left shoulder stiffness. She has equal loss of active and passive range of motion. Radiographs are normal. Which of the following is true regarding adhesive capsulitis in diabetic patients compared to idiopathic cases?

Explanation

Diabetic patients with adhesive capsulitis have a higher incidence of bilateral involvement, more severe symptoms, and a higher failure rate with conservative management compared to those with idiopathic adhesive capsulitis.

Question 52

A 50-year-old man undergoes a latissimus dorsi tendon transfer for an irreparable posterosuperior rotator cuff tear. Biomechanically, this transfer improves shoulder elevation primarily through which of the following mechanisms?

Explanation

The latissimus dorsi is an out-of-phase muscle that primarily acts via a tenodesis effect to depress the humeral head. This provides a stable fulcrum, allowing the native deltoid muscle to efficiently elevate the arm.

Question 53

A 65-year-old man with primary glenohumeral osteoarthritis presents with a Walch B2 glenoid demonstrating 22 degrees of retroversion. He is scheduled for an anatomic total shoulder arthroplasty. If eccentric reaming is chosen to correct the version, what is the maximum recommended correction before significantly risking glenoid vault violation and peg perforation?

Explanation

Eccentric reaming is typically limited to 10 to 15 degrees of correction. Reaming beyond 15 degrees significantly reduces the subchondral bone stock, violating the glenoid vault and increasing the risk of early component loosening and peg perforation.

Question 54

Which of the following best describes the biomechanical alteration achieved by a Grammont-style reverse total shoulder arthroplasty?

Explanation

The Grammont-style reverse total shoulder arthroplasty medializes and inferiorly shifts 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 55

A 28-year-old professional volleyball player presents with isolated weakness in external rotation of the dominant shoulder. Abduction strength is 5/5. MRI reveals a paralabral cyst. Where is the cyst most likely located and which nerve is compressed?

Explanation

Compression of the suprascapular nerve at the spinoglenoid notch affects only the infraspinatus, causing isolated external rotation weakness. Compression at the suprascapular notch would affect both the supraspinatus and infraspinatus, causing weakness in both abduction and external rotation.

Question 56

Which of the following arteries is considered the predominant blood supply to the humeral head, making its preservation critical during proximal humerus fracture fixation?

Explanation

Recent anatomical perfusion studies have demonstrated that the posterior humeral circumflex artery provides the predominant blood supply to the humeral head (approximately 64%). This contrasts with older literature which favored the anterior humeral circumflex.

Question 57

A 22-year-old collegiate baseball pitcher presents with posterior shoulder pain during the late cocking and early acceleration phases of throwing. Examination demonstrates a glenohumeral internal rotation deficit (GIRD) of 25 degrees. What is the primary pathoanatomy associated with this condition?

Explanation

Internal impingement occurs in overhead athletes when the arm is in maximum abduction and external rotation. This position causes the articular surface of the supraspinatus and infraspinatus to abut the posterosuperior glenoid rim and labrum, potentially leading to partial cuff tears.

Question 58

A 48-year-old construction worker presents with a symptomatic Type II superior labrum anterior and posterior (SLAP) tear confirmed on MRI. He has failed 6 months of physical therapy. Based on recent literature, what is the recommended surgical management for this patient?

Explanation

In patients over 40 years old, biceps tenodesis has been shown to yield higher patient satisfaction, better functional outcomes, and lower revision rates compared to arthroscopic SLAP repair. SLAP repair in this demographic is associated with significant postoperative stiffness.

Question 59

A 30-year-old bodybuilder experiences a sudden "pop" in his anterior axilla while performing a heavy bench press. Examination reveals loss of the anterior axillary fold and weakness in internal rotation. MRI confirms a rupture of the sternal head of the pectoralis major. Which of the following describes the correct anatomic relationship of the sternal head insertion?

Explanation

The pectoralis major tendon undergoes a 180-degree twist before inserting onto the lateral lip of the bicipital groove. The sternal head twists to insert deep and proximal to the clavicular head, placing it under maximal tension during the terminal eccentric phase of a bench press.

Question 60

A 22-year-old competitive rugby player presents with his fourth anterior shoulder dislocation this season. A CT scan of the shoulder reveals 26% anterior glenoid bone loss. He has a positive apprehension test and an engaging Hill-Sachs lesion. Which of the following is the most appropriate surgical management?

Explanation

In young collision athletes with recurrent anterior instability and critical glenoid bone loss (>20-25%), a Latarjet procedure (coracoid transfer) is indicated. Arthroscopic Bankart repair has an unacceptably high failure rate in the setting of significant bone loss.

Question 61

A 35-year-old overhead athlete complains of poorly localized posterior shoulder pain and fatigue with throwing. MRI demonstrates isolated atrophy and fatty infiltration of the teres minor muscle. Compression of the neurovascular bundle in the quadrilateral space is suspected. What structures are at risk in this anatomic space?

Explanation

Quadrilateral space syndrome involves compression of the axillary nerve and posterior circumflex humeral artery. The space is bounded by the teres minor, teres major, long head of the triceps, and the surgical neck of the humerus.

Question 62

A 28-year-old weightlifter felt a sudden "pop" in his anterior chest while performing a heavy bench press. Examination reveals ecchymosis over the anterior axillary fold and weakness in internal rotation and adduction. MRI confirms a complete rupture of the sternal head of the pectoralis major at its insertion. What is the most appropriate management?

Explanation

Pectoralis major ruptures most commonly occur at the sternal head insertion during eccentric loading. Surgical repair is recommended for young, active individuals to restore adduction and internal rotation strength and improve cosmetic contour.

Question 63

A 30-year-old professional volleyball player presents with insidious onset of right shoulder weakness. Examination shows full active range of motion and normal strength in abduction, but marked weakness in external rotation with the arm at the side. MRI reveals a paralabral cyst in the spinoglenoid notch. Which muscle is primarily affected?

Explanation

Compression of the suprascapular nerve at the spinoglenoid notch affects only the infraspinatus, causing isolated external rotation weakness. Cysts in this location are frequently associated with posterior labral tears.

Question 64

A 78-year-old female sustains a comminuted 4-part proximal humerus fracture after a fall. Radiographs demonstrate a valgus-impacted head, a head-split component, and severe osteopenia. Which of the following surgical options offers the most reliable restoration of forward elevation in this patient?

Explanation

In elderly patients with complex 4-part proximal humerus fractures and poor bone quality, reverse total shoulder arthroplasty provides reliable pain relief and functional restoration. It bypasses the need for tuberosity healing to achieve active forward elevation.

Question 65

A 45-year-old mechanic presents with shoulder pain and difficulty lifting heavy objects above his head. On examination, having the patient perform a wall push-up exacerbates medial prominence of the scapula. This clinical finding is most characteristic of an injury to which of the following nerves?

Explanation

Medial scapular winging is caused by serratus anterior paralysis due to long thoracic nerve injury. It is classically accentuated by having the patient perform a wall push-up to resist forward elevation.

Question 66

A 21-year-old collegiate baseball pitcher reports insidious onset of posterior shoulder pain. Examination reveals a 25-degree deficit in glenohumeral internal rotation on the dominant arm compared to the contralateral side, with normal total arc of motion. What is the most appropriate initial management?

Explanation

Glenohumeral internal rotation deficit (GIRD) is common in overhead athletes and relates to posterior capsular contracture. The initial and most effective management is a stretching program focusing on the posteroinferior capsule, such as sleeper stretches.

Question 67

A 55-year-old male presents with persistent anterior shoulder pain and weakness after falling on an outstretched hand 3 weeks ago. On examination, he has a positive bear-hug test and increased passive external rotation compared to the uninjured side. Which tendon is most likely torn?

Explanation

The subscapularis tendon is tested using the belly-press, lift-off, and bear-hug tests. Traumatic tears lead to increased passive external rotation and weakness in active internal rotation.

Question 68

A 72-year-old female presents with chronic shoulder pain and inability to actively elevate her arm above 45 degrees. Radiographs demonstrate superior migration of the humeral head articulating with the acromion, consistent with Hamada grade 3 cuff tear arthropathy. Her axillary nerve is intact. What is the most appropriate surgical treatment?

Explanation

Reverse shoulder arthroplasty is the treatment of choice for rotator cuff tear arthropathy with pseudoparalysis. It relies on a functioning deltoid muscle and intact axillary nerve to elevate the arm, altering the joint's biomechanics.

Question 69

A 40-year-old male presents with agonizing right shoulder pain that began 2 weeks ago and lasted for 10 days before subsiding. He now notes profound weakness when trying to abduct or externally rotate the arm. MRI of the shoulder is unremarkable. EMG shows acute denervation in the supraspinatus and deltoid. What is the most likely diagnosis?

Explanation

Parsonage-Turner syndrome (idiopathic brachial neuritis) presents with severe, acute shoulder pain followed by patchy weakness and atrophy of the shoulder girdle. Management is primarily supportive, as the condition is usually self-limiting over 1-2 years.

Question 70

A 45-year-old female presents with anterior shoulder pain. Ultrasound evaluation demonstrates an empty bicipital groove, with the long head of the biceps tendon displaced medially. This finding is highly correlated with a tear of which of the following structures?

Explanation

Medial subluxation of the long head of the biceps tendon is pathognomonic for an injury to the subscapularis tendon and the coracohumeral ligament, which comprise the medial biceps sling. Surgical management often involves subscapularis repair and biceps tenodesis.

Question 71

A 40-year-old diabetic female presents to the emergency department with acute, excruciating shoulder pain without preceding trauma. Radiographs show a large, fluffy, ill-defined calcific deposit in the supraspinatus tendon. During which phase of calcific tendinitis does the patient typically experience the most severe pain?

Explanation

Calcific tendinitis causes the most severe, acute pain during the resorptive phase. In this phase, the calcific deposit becomes highly vascularized, undergoes phagocytosis, and takes on a toothpaste-like consistency.

Question 72

An 18-year-old hockey player sustains a direct blow to his medial clavicle. He presents with severe pain, a palpable depression at the sternoclavicular joint, dysphagia, and mild dyspnea. What is the most appropriate next step in management?

Explanation

Posterior sternoclavicular dislocations are orthopedic emergencies due to the risk of airway, vascular, or esophageal compression. A CT scan of the chest is diagnostic, and urgent reduction in the OR with cardiothoracic surgery backup is required.

Question 73

A 50-year-old manual laborer presents with a massive, retracted, irreparable posterosuperior rotator cuff tear. He has significant weakness in external rotation and a positive Hornblower's sign. The glenohumeral joint shows no arthritic changes. Which of the following tendon transfers is best indicated to restore active external rotation?

Explanation

For a young or active patient with an irreparable posterosuperior rotator cuff tear, a latissimus dorsi or lower trapezius tendon transfer can restore active external rotation and forward elevation. It provides a biologic option to improve kinematics in a joint without significant arthropathy.

Question 74

A 19-year-old female gymnast complains of bilateral shoulder pain and a feeling of instability. Physical exam reveals a positive sulcus sign, excessive anterior and posterior translation, and a Beighton score of 6/9. What is the most appropriate primary treatment?

Explanation

Multidirectional instability (MDI) is primarily treated with a prolonged, minimum 6-month course of physical therapy focusing on periscapular and rotator cuff strengthening. Surgical stabilization is strictly reserved for patients who fail extensive conservative management.

Question 75

A 35-year-old male is evaluated in the emergency department following an unprovoked generalized tonic-clonic seizure. He complains of severe shoulder pain and his arm is locked in an internally rotated position. An AP radiograph demonstrates a symmetric "light bulb" appearance of the humeral head without an obvious fracture. What is the most likely diagnosis?

Explanation

Posterior shoulder dislocations commonly occur following seizures, electrical shocks, or high-energy trauma. The arm is typically locked in internal rotation, and the AP radiograph classically shows a "light bulb" sign due to the internal rotation of the humeral head.

Question 76

In the design and biomechanics of a reverse total shoulder arthroplasty (RSA), how does the prosthesis primarily compensate for a deficient rotator cuff to allow active forward elevation?

Explanation

Reverse shoulder arthroplasty shifts the center of rotation medially and distally. This increases the lever arm of the deltoid muscle and improves its resting tension, allowing it to elevate the arm without a functioning rotator cuff.

Question 77

A 52-year-old male recreational tennis player presents with deep shoulder pain and a clicking sensation. MRI arthrogram shows a type II SLAP tear. He has mild AC joint arthrosis but an otherwise intact rotator cuff. What is the most appropriate surgical management for this specific lesion in this demographic?

Explanation

In older patients (typically >40-50 years) with symptomatic SLAP II tears, primary biceps tenodesis yields superior and more reliable clinical outcomes than SLAP repair. SLAP repair in this demographic has a significantly higher risk of postoperative stiffness and residual pain.

Question 78

A 38-year-old male complains of a drooping shoulder and lateral scapular winging 6 months after undergoing a radical neck dissection for squamous cell carcinoma. He has difficulty sustaining abduction above 90 degrees. Which nerve was most likely injured during his prior surgery?

Explanation

Lateral scapular winging and shoulder droop are classic signs of trapezius palsy, which is typically due to iatrogenic injury to the spinal accessory nerve (CN XI) during posterior triangle neck surgeries. The Eden-Lange muscle transfer is the surgical treatment of choice if recovery fails.

Question 79

A 25-year-old cyclist falls directly onto the point of his right shoulder. Clinical examination reveals profound tenting of the skin over the AC joint. Radiographs show the distal clavicle is displaced superiorly by 150% of the acromion width. The coracoclavicular distance is 28 mm (normal 11-13 mm). According to the Rockwood classification, what is the best treatment option?

Explanation

A Rockwood Type V acromioclavicular joint injury involves >100% superior displacement of the clavicle with stripping of the deltopectoral fascia. Due to the severe instability, it typically requires operative intervention with coracoclavicular (CC) ligament reconstruction.

Question 80

A 40-year-old laborer presents with chronic, refractory anterior shoulder pain and profound internal rotation weakness. MRI shows a massive, retracted, and fatty-infiltrated subscapularis tendon tear (Goutallier stage 4), with completely intact supraspinatus and infraspinatus tendons. What is the most appropriate surgical management?

Explanation

Pectoralis major transfer is indicated for younger, active patients with an isolated, irreparable subscapularis tear. Latissimus dorsi and lower trapezius transfers are typically reserved for irreparable posterosuperior rotator cuff tears.

Question 81

A 22-year-old rugby player presents with recurrent anterior shoulder instability after multiple dislocations. A 3D CT reconstruction reveals an 'inverted pear' shaped glenoid with 25% anterior bone loss. What is the most appropriate definitive management?

Explanation

An 'inverted pear' glenoid indicates critical bone loss (usually >20-25%), which is an absolute contraindication for soft-tissue stabilization alone. The Latarjet procedure restores stability through both a bony augmentation and the dynamic sling effect of the conjoint tendon.

Question 82

When evaluating a displaced proximal humerus fracture, which of the following radiographic findings is the most reliable predictor of subsequent humeral head ischemia?

Explanation

According to Hertel's criteria, the most reliable predictors of humeral head ischemia are a disrupted medial hinge, a short calcar length attached to the articular segment (<8 mm), and an anatomic neck fracture. Disruption of the medial calcar hinge compromises the ascending branches of the anterior humeral circumflex artery.

Question 83

A 28-year-old elite volleyball player complains of vague posterior shoulder pain and weakness during her serve. Examination shows normal forward elevation and internal rotation, but weakness in isolated external rotation with the arm at the side. MRI is most likely to reveal a paralabral cyst at which location?

Explanation

A paralabral cyst at the spinoglenoid notch compresses the suprascapular nerve after it has already innervated the supraspinatus, leading to isolated infraspinatus weakness. Cysts at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 84

A 72-year-old woman is 6 months postoperative from a reverse total shoulder arthroplasty for cuff tear arthropathy. She reports a sudden onset of lateral shoulder pain after lifting a light box. Radiographs reveal a non-displaced fracture of the acromion base. What is the most appropriate initial management?

Explanation

Non-displaced acromial stress fractures (Levy Type 1 or 2) after reverse total shoulder arthroplasty are typically treated non-operatively with sling immobilization. Operative fixation is generally reserved for displaced fractures causing severe deltoid dysfunction or painful nonunions.

Question 85

A 45-year-old woman presents with right shoulder aching and fatigue. She underwent a cervical lymph node biopsy 4 months ago. Examination reveals lateral winging of the scapula and inability to actively abduct the arm past 90 degrees. Which nerve is most likely injured?

Explanation

The spinal accessory nerve (CN XI) innervates the trapezius, and its iatrogenic injury during posterior triangle neck biopsies causes lateral winging of the scapula and a dropped shoulder. Injury to the long thoracic nerve causes medial winging due to serratus anterior paralysis.

Question 86

A 35-year-old cyclist falls directly onto his shoulder and sustains a closed fracture of the distal clavicle. Radiographs show the fracture line is medial to the coracoclavicular ligaments, and the proximal fragment is displaced superiorly by 100%. What is the most appropriate classification and typical treatment for this injury?

Explanation

This describes a Neer Type II distal clavicle fracture, characterized by a fracture medial to intact coracoclavicular ligaments with significant superior displacement of the proximal fragment. Due to a high rate of nonunion with conservative care, operative fixation is recommended.

Question 87

A 55-year-old male construction worker presents with persistent deep shoulder pain. Examination reveals a positive O'Brien test and no rotator cuff weakness. MRI arthrogram demonstrates an isolated Type II SLAP lesion. After failure of a 6-month trial of physical therapy, what is the most appropriate surgical intervention?

Explanation

In patients older than 40-50 years with symptomatic Type II SLAP lesions, biceps tenodesis provides more reliable pain relief and higher return to work rates compared to SLAP repair. SLAP repairs in older populations are associated with significant postoperative stiffness and higher clinical failure rates.

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

Orthopedic Shoulder 2026 MCQs: Board Review Questions & Answers (Part 2)

Key Takeaway

Orthopedic Shoulder 2026 MCQs: Board Review Questions & Answers (Part 2)

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