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

Placing the glenosphere inferiorly in reverse total shoulder arthroplasty accomplishes which of the following biomechanical effects?

Explanation

Placing the glenosphere inferiorly in a reverse total shoulder arthroplasty lowers the center of rotation, which tensions the deltoid and increases its mechanical advantage. It also helps minimize the risk of inferior scapular notching.

Question 27

A 24-year-old male sustains a traction injury to his shoulder and presents with lateral scapular winging. Which of the following nerve-muscle combinations is most likely injured?

Explanation

Lateral scapular winging is typically caused by injury to the spinal accessory nerve, resulting in trapezius palsy. Medial winging is caused by long thoracic nerve injury, leading to serratus anterior palsy.

Question 28

A 55-year-old laborer has an irreparable, massive posterosuperior rotator cuff tear with an intact subscapularis. He lacks active external rotation. Which tendon transfer is most appropriate?

Explanation

Lower trapezius transfer (often with an interposition graft) is used to restore active external rotation in patients with an irreparable posterosuperior rotator cuff tear. Pectoralis major transfers are typically utilized for irreparable subscapularis tears.

Question 29

In planning for an anatomic total shoulder arthroplasty, preoperative CT shows a B2 glenoid with 25 degrees of retroversion. Which of the following is the most appropriate management of the glenoid?

Explanation

A B2 glenoid with excessive retroversion (>15-20 degrees) is best managed with an augmented glenoid component or bone grafting. Eccentric posterior reaming for 25 degrees of retroversion would remove excessive subchondral bone, severely risking component subsidence.

Question 30

Which physical examination test provides the highest sensitivity and specificity for diagnosing an upper border subscapularis tear?

Explanation

The bear-hug test has been shown to be highly sensitive and specific for upper subscapularis tendon tears. The lift-off test predominantly isolates the lower fibers of the subscapularis.

Question 31

After an anatomic total shoulder arthroplasty performed via a deltopectoral approach, a patient presents at 6 weeks with sudden onset of weakness in internal rotation and increased passive external rotation. What is the most likely complication?

Explanation

Sudden loss of internal rotation strength with increased passive external rotation shortly after an anatomic TSA (via a deltopectoral approach) is highly suspicious for failure of the subscapularis repair. Early surgical intervention is typically warranted.

Question 32

A 22-year-old collegiate baseball pitcher complains of posterior shoulder pain during the late cocking phase of throwing. He has a positive apprehension test, but pain is relieved with a relocation maneuver. What is the primary pathomechanics of this condition?

Explanation

Internal impingement in overhead throwing athletes occurs due to contact between the articular side of the posterosuperior rotator cuff and the posterosuperior labrum/glenoid during extreme abduction and external rotation.

Question 33

A 30-year-old professional volleyball player presents with isolated atrophy and weakness of the infraspinatus muscle. MRI reveals a paralabral cyst. At which of the following locations is the cyst most likely compressing the nerve?

Explanation

Compression of the suprascapular nerve at the spinoglenoid notch causes isolated infraspinatus weakness. Compression at the suprascapular notch generally affects both the supraspinatus and infraspinatus.

Question 34

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

Explanation

Absolute indications for operative fixation of a clavicle fracture include open fractures, neurovascular compromise, and severe skin compromise (such as impending skin breakdown). Shortening and complete displacement are relative indications.

Question 35

A 40-year-old male presents with vague posterior shoulder pain and weakness in external rotation. An MRI demonstrates fatty infiltration and atrophy isolated to the teres minor muscle. Which structure is most likely compressed?

Explanation

Quadrilateral space syndrome involves compression of the axillary nerve and posterior humeral circumflex artery. This typically results in isolated atrophy of the teres minor, though the deltoid may also be affected.

Question 36

During a Latarjet procedure, the coracoid is transferred through the subscapularis split. Which nerve is most at risk of injury when dissecting medial to the conjoint tendon?

Explanation

The musculocutaneous nerve penetrates the coracobrachialis approximately 3-5 cm distal to the coracoid process. It is the structure most at risk when dissecting medial to the conjoint tendon during a Latarjet procedure.

Question 37

A 22-year-old collegiate rugby player presents with his fourth anterior shoulder dislocation this season. A 3D CT scan demonstrates a 25% anterior glenoid bone loss. He wishes to return to contact sports. What is the most appropriate definitive surgical management?

Explanation

A glenoid bone loss of greater than 20-25% is a critical defect associated with high failure rates following soft-tissue (Bankart) repair alone. The Latarjet procedure transfers the coracoid process to the anterior glenoid, restoring the bony arc and providing a dynamic sling effect via the conjoined tendon.

Question 38

A 72-year-old female presents with severe, intractable right shoulder pain. Active forward elevation is limited to 40 degrees (pseudoparalysis). Radiographs reveal an acromiohumeral distance of 2 mm and superior migration of the humeral head, but an intact anterior deltoid is noted on exam. What is the most appropriate surgical treatment?

Explanation

Pseudoparalysis with superior humeral head migration and acetabularization of the acromion indicates severe rotator cuff tear arthropathy. Reverse total shoulder arthroplasty is the treatment of choice as it medializes and distalizes the center of rotation, allowing the intact deltoid to elevate the arm.

Question 39

A 28-year-old male presents with a dull ache around his shoulder and noticeable medial scapular winging when performing a wall push-up. Which muscle is denervated, and what is the root origin of the affected nerve?

Explanation

Medial scapular winging is caused by paralysis of the serratus anterior muscle, which is innervated by the long thoracic nerve. The long thoracic nerve originates from the roots of C5, C6, and C7.

Question 40

A 31-year-old professional volleyball player presents with painless weakness in shoulder external rotation. Abduction strength is normal. MRI demonstrates a paralabral cyst causing nerve compression. Where is the cyst most likely located?

Explanation

Isolated weakness of the infraspinatus (external rotation) with normal supraspinatus function (abduction) indicates suprascapular nerve entrapment at the spinoglenoid notch. Compression at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 41

A 68-year-old female sustains a 4-part proximal humerus fracture. According to Hertel's criteria, which of the following radiographic findings is the strongest predictor of subsequent humeral head ischemia?

Explanation

Hertel identified specific predictors for humeral head ischemia in proximal humerus fractures. A metaphyseal head extension (calcar length) of less than 8 mm, along with disruption of the medial hinge, strongly predicts ischemia and potential avascular necrosis.

Question 42

A 62-year-old male, 14 months post-anatomic total shoulder arthroplasty, presents with insidious onset of shoulder stiffness and mild pain. Inflammatory markers are strictly normal. Joint aspiration grows Cutibacterium acnes. Which of the following best describes this organism?

Explanation

Cutibacterium acnes is a slow-growing, Gram-positive anaerobic (or microaerophilic) bacillus commonly found in the normal skin flora of the shoulder. It is a frequent cause of indolent periprosthetic joint infections following shoulder arthroplasty.

Question 43

A 35-year-old bodybuilder tears his pectoralis major tendon while bench pressing. Operative repair is planned. Which of the following accurately describes the normal anatomic insertion of the sternal head relative to the clavicular head on the humerus?

Explanation

The pectoralis major tendon undergoes a 180-degree twist before inserting on the humerus. This twisting causes the sternal (inferior) head to insert posterior (deep) and proximal (superior) relative to the clavicular head.

Question 44

A 24-year-old male undergoes a Latarjet procedure. Postoperatively, he exhibits profound weakness in elbow flexion and supination, along with numbness over the lateral forearm. Which nerve was most likely injured by vigorous retractor placement deep to the conjoined tendon?

Explanation

The musculocutaneous nerve enters the coracobrachialis approximately 3-8 cm distal to the coracoid tip. Vigorous medial retraction of the conjoined tendon during the Latarjet procedure places this nerve at high risk for a traction neuropathy.

Question 45

A 65-year-old female presents with pseudoparalysis of the right shoulder, a massive irreducible rotator cuff tear, and mild glenohumeral osteoarthritis. What is the most appropriate surgical treatment?

Explanation

Reverse total shoulder arthroplasty (RTSA) is the treatment of choice for elderly patients with massive, irreparable rotator cuff tears and pseudoparalysis. Hemiarthroplasty and anatomic TSA rely on a functional rotator cuff, while tendon transfers or SCR are less reliable in the setting of true pseudoparalysis.

Question 46

A 22-year-old contact athlete experiences recurrent anterior shoulder dislocations. CT imaging demonstrates a 25% anteroinferior glenoid bone loss. Which of the following is the most appropriate definitive surgical management?

Explanation

The Latarjet procedure (coracoid transfer) is indicated for anterior shoulder instability in patients with greater than 20-25% glenoid bone loss. Soft tissue repairs alone have an unacceptably high failure rate in young contact athletes with significant bone loss.

Question 47

A 70-year-old female undergoes locking plate fixation of a 3-part proximal humerus fracture. At 6 months, she presents with progressive shoulder pain, and radiographs show superior screw cutout into the joint. What is the most likely initial technical error during surgery?

Explanation

Loss of medial hinge/calcar support is a major risk factor for varus collapse and subsequent superior screw cutout in locked plating of proximal humerus fractures. Proper restoration of the inferomedial cortex is crucial to prevent this complication.

Question 48

A 45-year-old male presents with shoulder pain and weakness following a fall. Physical examination reveals a positive bear hug test and a positive belly press test. Which of the following rotator cuff tendons is most likely injured?

Explanation

The bear hug and belly press tests are highly sensitive and specific for evaluating subscapularis integrity. These tests isolate the subscapularis function from the other internal rotators like the pectoralis major.

Question 49

A 30-year-old weightlifter feels a sharp pop in his anterior axilla while bench pressing. Examination reveals loss of the anterior axillary fold and weakness in internal rotation. What is the recommended management for an acute complete tear at the humeral insertion?

Explanation

Acute operative repair of completely ruptured pectoralis major tendons at the humeral insertion yields significantly better strength, cosmesis, and functional outcomes compared to nonoperative management in young active individuals.

Question 50

A 40-year-old female presents with acute, severe right shoulder pain without trauma. Radiographs show a dense, homogenous calcific deposit in the supraspinatus tendon. During which phase of calcific tendinitis does the patient typically experience the most acute pain?

Explanation

Calcific tendinitis causes the most severe, acute pain during the resorptive phase. In this phase, the calcium deposit takes on a toothpaste-like consistency and vascular invasion occurs, leading to profound inflammation.

Question 51

A 28-year-old elite volleyball player complains of vague posterior shoulder pain and weakness. Examination shows isolated atrophy of the infraspinatus. An MRI confirms a paralabral cyst causing nerve compression. Where is the most likely location of this cyst?

Explanation

Entrapment of the suprascapular nerve at the spinoglenoid notch results in isolated infraspinatus weakness and atrophy. Entrapment at the suprascapular notch would affect both the supraspinatus and the infraspinatus.

Question 52

A 55-year-old manual laborer has a massive, irreparable posterosuperior rotator cuff tear with an intact subscapularis, no glenohumeral arthritis, and no pseudoparalysis. What is the most appropriate joint-preserving surgical option?

Explanation

Superior capsular reconstruction (SCR) is indicated for younger, active patients with massive, irreparable posterosuperior rotator cuff tears, intact subscapularis, and no glenohumeral arthritis to restore superior joint stability.

Question 53

How does a reverse total shoulder arthroplasty (RTSA) fundamentally improve shoulder function in a patient with advanced rotator cuff tear arthropathy?

Explanation

RTSA improves function by medializing and distalizing the joint's center of rotation. This increases the lever arm and resting tension of the deltoid, allowing it to initiate abduction without a functional rotator cuff.

Question 54

A 25-year-old cyclist falls directly onto his shoulder. Radiographs demonstrate 150% superior displacement of the distal clavicle relative to the acromion, with a significantly increased coracoclavicular distance. What is the classification and typical management of this injury?

Explanation

A Rockwood Type V AC joint injury is characterized by 100-300% superior displacement of the clavicle due to disruption of the AC/CC ligaments and the deltotrapezial fascia. It is typically managed operatively in young, active patients.

Question 55

A 35-year-old male presents with two weeks of sudden, severe, unrelenting right shoulder pain. As the pain subsides, he develops profound weakness in shoulder abduction and external rotation. EMG shows denervation of the deltoid and supraspinatus. What is the most likely diagnosis?

Explanation

Parsonage-Turner syndrome presents with an acute onset of severe, unrelenting shoulder pain followed by patchy muscle weakness and atrophy as the pain subsides. It is an idiopathic brachial neuritis typically treated supportively.

Question 56

A 45-year-old recreational tennis player has persistent shoulder pain despite 6 months of nonoperative management. An MRI arthrogram shows an isolated Type II SLAP tear. What is the most predictable surgical treatment to relieve his pain and restore function?

Explanation

In patients over age 40, biceps tenodesis provides more predictable pain relief and functional improvement for Type II SLAP tears compared to arthroscopic SLAP repair, which carries a higher rate of stiffness in this age group.

Question 57

A 72-year-old woman undergoes a reverse total shoulder arthroplasty. At her 1-year follow-up, she complains of mild pain. Radiographs reveal inferior scapular notching (Sirveaux grade 2). Which of the following surgical modifications during the index procedure would have most likely decreased the risk of this complication?

Explanation

Inferior scapular notching is a common complication of reverse TSA. Inferior translation, inferior tilt, lateralization of the glenosphere, and using a lower humeral neck-shaft angle decrease the risk of notching.

Question 58

A 45-year-old man presents with chronic shoulder pain and stiffness after a seizure 6 weeks ago. Physical examination reveals an inability to externally rotate the shoulder beyond neutral. An axillary radiograph shows a defect on the anteromedial humeral head engaging the posterior glenoid. The defect involves 30% of the articular surface. What is the most appropriate surgical management?

Explanation

The patient has a missed posterior shoulder dislocation with a reverse Hill-Sachs lesion. For defects involving 25-40% of the articular surface, transfer of the subscapularis or lesser tuberosity into the defect is recommended.

Question 59

A 65-year-old woman undergoes open reduction and internal fixation of a 3-part proximal humerus fracture with a locked plate. Which of the following technical factors is most critical for minimizing the risk of varus collapse and subsequent screw cut-out?

Explanation

Placement of calcar screws into the inferomedial quadrant of the humeral head provides essential medial support. This significantly reduces the risk of varus collapse and secondary screw cut-out.

Question 60

A 22-year-old elite baseball pitcher presents with vague anterior shoulder pain and a subjective "dead arm" feeling during the late cocking phase of throwing. MRI arthrogram reveals a type II SLAP tear. Nonoperative management has failed. What is the most appropriate surgical treatment?

Explanation

In a young, elite overhead athlete with a symptomatic type II SLAP tear failing conservative management, arthroscopic SLAP repair is the procedure of choice. Biceps tenodesis is generally preferred for older or non-overhead athletes.

Question 61

A 32-year-old competitive weightlifter feels a sudden pop in his anterior axilla while bench pressing. Examination reveals loss of the anterior axillary fold and weakness in internal rotation. MRI confirms a complete rupture of the pectoralis major at the sternocostal head insertion. What is the optimal timing and treatment?

Explanation

Pectoralis major ruptures at the humeral insertion in young, active patients should be repaired acutely. Early repair yields superior cosmetic and functional results, particularly restoring peak torque.

Question 62

A 28-year-old professional volleyball player presents with insidious onset of poorly localized posterior shoulder pain and weakness in external rotation. Examination reveals isolated atrophy of the infraspinatus. MRI demonstrates a paralabral cyst in the spinoglenoid notch. Which labral tear is most commonly associated with this pathology?

Explanation

Paralabral cysts in the spinoglenoid notch cause isolated compression of the suprascapular nerve branch to the infraspinatus. These cysts are most commonly associated with posterior labral tears.

Question 63

A 24-year-old professional hockey player sustains a direct blow to the point of his shoulder. Radiographs demonstrate 120% superior displacement of the distal clavicle relative to the acromion, and it is reducible on exam. What is the most appropriate management?

Explanation

This describes a Type III acromioclavicular (AC) joint separation. The initial treatment for most Type III injuries, even in high-level contact athletes, is nonoperative management.

Question 64

A 42-year-old man presents with sudden, severe shoulder pain that started 3 weeks ago without trauma. The pain has now resolved, but he notices profound weakness in raising his arm and a "winging" scapula. EMG reveals denervation of the serratus anterior and supraspinatus. What is the most likely diagnosis?

Explanation

Parsonage-Turner syndrome typically presents with a sudden onset of severe shoulder pain followed by patchy weakness and muscle atrophy as the pain subsides. Management is generally supportive.

Question 65

A 55-year-old manual laborer presents with chronic, severe shoulder weakness. He has an intact subscapularis, but MRI shows a massive, retracted, and fatty-infiltrated tear of the supraspinatus and infraspinatus (Goutallier stage 4). He has no glenohumeral arthritis. Which of the following is the most appropriate surgical option?

Explanation

For a young or active patient with an irreparable posterosuperior rotator cuff tear without arthritis and an intact subscapularis, a latissimus dorsi tendon transfer is an appropriate salvage procedure.

Question 66

A 68-year-old man with primary glenohumeral osteoarthritis is being considered for an anatomic total shoulder arthroplasty (TSA). Preoperative CT scan reveals a biconcave glenoid with 25 degrees of retroversion and significant posterior humeral head subluxation. What is the most appropriate surgical strategy?

Explanation

A Walch B2 glenoid with excessive retroversion (>15-20 degrees) and posterior subluxation is prone to early glenoid component loosening in anatomic TSA. Reverse TSA is generally preferred to provide stability and avoid early failure.

Question 67

A 21-year-old rugby player has recurrent anterior shoulder dislocations. Imaging reveals a 25% anterior glenoid bone loss and an engaging Hill-Sachs lesion. He undergoes a Latarjet procedure. Which structure is carefully preserved and utilized to create a "sling" effect during this procedure?

Explanation

The Latarjet procedure involves transferring the coracoid process with the attached conjoint tendon through a split in the subscapularis. The conjoint tendon acts as a dynamic sling to prevent anterior translation of the humerus.

Question 68

A 26-year-old woman complains of painful crepitus and snapping at the superomedial border of her scapula with arm movement. Nonoperative measures have failed after 6 months. She is scheduled for surgery. Excision of which of the following bursae is typically performed along with resection of the superomedial angle?

Explanation

Snapping scapula syndrome often involves inflammation of the infraserratus and supraserratus bursae. Surgical management includes bursectomy of these spaces and resection of the superomedial angle of the scapula.

Question 69

A 19-year-old male is brought to the ER after a high-speed motor vehicle collision. He has severe pain over his medial clavicle, shortness of breath, and mild dysphagia. Examination shows a depression over the medial clavicle. What is the most appropriate initial diagnostic imaging to confirm the suspected diagnosis?

Explanation

The patient has a posterior sternoclavicular joint dislocation, which is a medical emergency. A CT scan of the chest is the gold standard for diagnosis and assessing for compression of the trachea, esophagus, and great vessels.

Question 70

A 25-year-old professional tennis player presents with posterior shoulder pain during the cocking phase of serving. Exam shows a positive relocation test and glenohumeral internal rotation deficit (GIRD) of 25 degrees compared to the contralateral side. What is the primary pathophysiologic mechanism of his shoulder pain?

Explanation

Internal impingement involves the pathologic contact of the articular surface of the supraspinatus and infraspinatus tendons against the posterosuperior glenoid and labrum during extreme abduction and external rotation.

Question 71

An 81-year-old woman presents with an inability to actively elevate her right arm above 40 degrees. She has full passive range of motion. Radiographs show superior migration of the humeral head with an acromiohumeral interval of 3 mm. MRI confirms a massive, retracted rotator cuff tear. Her condition is best classified as:

Explanation

Pseudoparalysis of the shoulder is defined as an inability to actively elevate the arm past 90 degrees in the presence of full passive range of motion. It is typically due to a massive rotator cuff tear.

Question 72

A 42-year-old man presents with a locked posterior shoulder dislocation after a seizure. CT scan reveals an anteromedial humeral head defect (reverse Hill-Sachs lesion) involving 30% of the articular surface. Which of the following is the most appropriate surgical management?

Explanation

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

Question 73

A 26-year-old elite volleyball player complains of vague posterior shoulder pain and fatigue with overhead activities. Physical exam reveals isolated atrophy of the teres minor. An MRI shows isolated fatty infiltration of the teres minor and a cystic structure in the quadrilateral space. Which vascular structure is most likely compressed alongside the affected nerve?

Explanation

Quadrilateral space syndrome involves compression of the axillary nerve and the posterior humeral circumflex artery. This typically results in isolated teres minor atrophy and poorly localized posterior shoulder pain.

Question 74

A 30-year-old male weightlifter felt a sudden 'pop' in his anterior axilla while performing a heavy bench press. Examination reveals loss of the anterior axillary contour and weakness in internal rotation. If surgical repair is undertaken, which of the following describes the normal anatomic footprint of the ruptured structure?

Explanation

The pectoralis major tendon has two main heads. The sternal head twists 180 degrees to insert deep and proximal to the clavicular head on the lateral lip of the bicipital groove.

Question 75

A 58-year-old laborer presents with an irreparable posterosuperior rotator cuff tear. He has profound weakness in external rotation and a positive Hornblower's sign. He has intact forward elevation and no significant glenohumeral arthritis. Which of the following tendon transfers is most appropriate?

Explanation

Lower trapezius transfer (often with an Achilles allograft) is highly effective for restoring external rotation in patients with irreparable posterosuperior cuff tears and a positive Hornblower's sign. It has a more direct line of pull for external rotation compared to the latissimus dorsi.

Question 76

A 72-year-old woman is 3 years status post reverse total shoulder arthroplasty (RTSA) using a Grammont-style prosthesis. Radiographs show a grade 3 inferior scapular notch. Which of the following technical errors during the index procedure most significantly increases the risk of this complication?

Explanation

Superior placement of the baseplate in RTSA increases the risk of scapular notching due to impingement of the humeral tray against the inferior scapular neck. Inferior overhang, inferior tilt, and lateralization are protective against notching.

Question 77

Recent quantitative anatomical studies investigating the arterial supply to the proximal humerus have redefined classic teachings. Based on these contemporary studies, which artery provides the majority of the blood supply to the humeral head?

Explanation

Recent studies (e.g., Hettrich et al.) demonstrated that the posterior humeral circumflex artery supplies approximately 64% of the blood to the humeral head. This contradicts older literature which emphasized the anterolateral ascending branch of the anterior humeral circumflex artery.

Question 78

A 22-year-old rugby player presents with recurrent anterior shoulder instability. A 3D CT scan reveals a 26% anterior glenoid bone loss. Which of the following is the most appropriate surgical intervention?

Explanation

Critical glenoid bone loss (>20-25%) in a young, high-demand athlete is an absolute indication for a bony augmentation procedure, such as the Latarjet procedure. Soft tissue repairs alone have an unacceptably high failure rate in this setting.

Question 79

A 29-year-old professional tennis player reports progressive weakness in his serving arm. Examination demonstrates normal supraspinatus strength but 3/5 strength in external rotation with the arm at the side. Atrophy is noted only in the infraspinatus fossa. Where is the most likely location of nerve compression?

Explanation

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

Question 80

A 45-year-old man falls directly onto his shoulder. Clinical examination and weight-bearing radiographs reveal a Type V acromioclavicular (AC) joint separation with 150% superior displacement of the clavicle relative to the acromion. What is the most appropriate management?

Explanation

Type V AC separations represent severe displacement (>100-300%) due to disruption of both the AC and CC ligaments, along with stripping of the deltotrapezial fascia. Surgical reconstruction of the CC ligaments is the standard of care.

Question 81

A 21-year-old baseball pitcher presents with posterior shoulder pain during the late cocking phase of throwing. MRI arthrogram shows undersurface fraying of the posterior supraspinatus and anterior infraspinatus tendons, along with posterosuperior labral fraying. What is the primary pathoanatomic mechanism?

Explanation

Internal impingement occurs in overhead athletes when the undersurface of the posterosuperior rotator cuff abuts the posterosuperior glenoid labrum during maximum abduction and external rotation (late cocking phase).

Question 82

A 66-year-old man with primary glenohumeral osteoarthritis presents for shoulder arthroplasty. A preoperative CT scan reveals a Walch B2 glenoid with 25 degrees of retroversion and posterior humeral head subluxation. When planning an anatomic total shoulder arthroplasty, what is the best strategy to address the glenoid?

Explanation

A Walch B2 glenoid is characterized by biconcavity, posterior wear, and retroversion. Management in anatomic TSA requires correcting the retroversion, typically via asymmetric (eccentric) posterior reaming or using a posteriorly augmented glenoid component to prevent premature posterior loosening.

Question 83

A 32-year-old woman develops prominent medial scapular winging three weeks after a severe viral illness. She has weakness in forward elevation but intact external rotation. EMG confirms an isolated nerve palsy. Which nerve-muscle pair is affected?

Explanation

Medial scapular winging (prominence of the medial border) is classic for serratus anterior paralysis due to long thoracic nerve palsy. Lateral winging is associated with trapezius paralysis from a spinal accessory nerve injury.

Question 84

A 40-year-old man presents with an acute onset of severe, unremitting right shoulder pain that woke him from sleep. After two weeks, the pain significantly improves, but he notices profound weakness in elevating his arm. MRI of the shoulder is unremarkable. What is the most likely diagnosis?

Explanation

Parsonage-Turner Syndrome classically presents with acute, severe pain followed by patchy weakness and muscle atrophy (often deltoid, rotator cuff, or periscapular muscles) as the pain resolves. It is typically a self-limiting viral or autoimmune neuritis.

Question 85

A 65-year-old man undergoes repair of a massive anterior rotator cuff tear (subscapularis) that is deemed irreparable intraoperatively. Which of the following tendon transfers is the most established option for restoring function?

Explanation

Transfer of the pectoralis major (specifically the sternal head or the entire tendon routed deep to the conjoined tendon) to the lesser tuberosity is the gold standard tendon transfer for an irreparable subscapularis tear.

Question 86

An 18-year-old high school football player sustains a posterior sternoclavicular (SC) joint dislocation. He presents to the emergency department with mild dysphagia and a feeling of fullness in his throat. Which of the following is the most appropriate next step in management?

Explanation

Posterior SC dislocations can compress vital mediastinal structures (trachea, esophagus, great vessels). Closed reduction should be attempted in the OR under general anesthesia with cardiothoracic surgery backup in case of catastrophic vascular injury.

Question 87

A 75-year-old woman with advanced osteoporosis sustains a 4-part proximal humerus fracture with significant comminution of the tuberosities. She is living independently and functionally active. Which of the following treatments provides the most reliable return of active forward elevation?

Explanation

In elderly patients with poor bone quality and severely comminuted 4-part proximal humerus fractures, reverse total shoulder arthroplasty provides a more reliable and predictable functional outcome (especially forward elevation) compared to ORIF or hemiarthroplasty, as it relies less on tuberosity healing.

Question 88

During physical examination of a patient with suspected rotator cuff pathology, the 'Bear Hug' test and the 'Belly-Press' test are positive, but the 'Lift-Off' test is negative. Which anatomical portion of the subscapularis is most likely torn?

Explanation

The 'Bear Hug' and 'Belly-Press' tests are highly sensitive for upper subscapularis tears. The 'Lift-Off' test requires internal rotation behind the back, which primarily isolates the lower portion of the subscapularis muscle.

Question 89

A 55-year-old diabetic woman presents with an 8-month history of a painfully stiff shoulder. She has severely restricted active and passive range of motion in all planes. Radiographs are normal. Which cytokine is most heavily implicated in the pathogenesis of her condition?

Explanation

Adhesive capsulitis is driven by excessive fibroblastic proliferation and collagen deposition. TGF-β is the primary cytokine responsible for this fibrotic cascade in the joint capsule.

Question 90

A 38-year-old male presents with chronic anterior shoulder pain. MRI shows a type II SLAP lesion. He undergoes arthroscopic SLAP repair using two suture anchors. Six months postoperatively, he complains of severe stiffness, lacking 30 degrees of external rotation. What is the most likely intraoperative technical error?

Explanation

Postoperative stiffness, particularly loss of external rotation, is the most common complication of SLAP repairs. It is frequently caused by over-tensioning the anterior-superior labrum or capturing the biceps anchor too tightly, essentially creating a functional capsulorrhaphy.

Question 91

A 13-year-old highly competitive baseball pitcher presents with insidious onset of proximal shoulder pain in his throwing arm. Radiographs reveal widening of the proximal humeral physis and sclerosis of the metaphysis. What is the definitive initial management?

Explanation

Little League Shoulder (proximal humeral epiphysiolysis) is an overuse injury caused by repetitive rotational torque. The standard of care is absolute cessation of throwing for typically 3 months until symptoms resolve and the physis shows radiographic healing.

Question 92

A 22-year-old professional rugby player presents with his fourth anterior shoulder dislocation. Advanced imaging reveals 25% anterior glenoid bone loss and an engaging Hill-Sachs lesion. Which of the following is the most appropriate surgical management?

Explanation

In collision athletes with significant anterior glenoid bone loss (>20-25%), isolated soft-tissue repairs have an unacceptably high failure rate. The Latarjet procedure (coracoid transfer) is the gold standard as it reconstructs the glenoid defect and provides a dynamic sling effect.

Question 93

A 28-year-old male volleyball player complains of vague posterior shoulder pain and isolated weakness in external rotation. Examination reveals normal internal rotation and abduction strength, but noticeable atrophy of the infraspinatus fossa. Which of the following is the most likely diagnosis?

Explanation

Entrapment of the suprascapular nerve at the spinoglenoid notch selectively involves the branch to the infraspinatus, causing isolated external rotation weakness. Entrapment at the suprascapular notch would also involve the supraspinatus, resulting in abduction weakness.

Question 94

A 72-year-old female presents with worsening shoulder pain 5 years after undergoing a Reverse Total Shoulder Arthroplasty (RTSA). Radiographs show a radiolucent line under the inferior glenosphere baseplate with associated bone loss (Sirveaux Grade 3 scapular notching). Which surgical factor is most associated with this complication?

Explanation

Scapular notching is a frequent complication in RTSA caused by mechanical impingement of the humeral component against the inferior scapular neck. Risk factors include superior tilt and superior placement of the glenoid baseplate, whereas inferior placement and tilt are protective.

Question 95

A 20-year-old collegiate baseball pitcher complains of posterior shoulder pain during the late cocking phase of throwing. Physical examination reveals 25 degrees less internal rotation compared to his contralateral arm, but his total arc of motion is equal bilaterally. What is the most appropriate initial management?

Explanation

This presentation describes Glenohumeral Internal Rotation Deficit (GIRD) with a preserved total arc of motion. The initial and most effective treatment is a physical therapy program emphasizing posteroinferior capsular stretching (e.g., sleeper stretches).

Question 96

A 45-year-old manual laborer presents with an irreparable, massive, retracted posterosuperior rotator cuff tear. His subscapularis is completely intact. He demonstrates profound weakness in external rotation with a positive Hornblower's sign, but no glenohumeral arthritis. Which of the following is the most appropriate surgical option?

Explanation

For a young patient with an irreparable posterosuperior tear and severe external rotation deficit, a tendon transfer is indicated. Lower trapezius transfer is favored because its line of pull closely mimics the native infraspinatus, making it superior to latissimus transfer for restoring external rotation.

Question 97

A 78-year-old female with known severe osteoporosis falls from a standing height. Radiographs reveal a highly displaced 4-part proximal humerus fracture with a head-split component. She is independent and medically fit for surgery. Which of the following treatments provides the most predictable functional outcome?

Explanation

In elderly patients with osteoporotic bone and complex fractures (such as 4-part and head-split), RTSA provides more predictable pain relief and functional restoration than ORIF. Hemiarthroplasty outcomes are highly dependent on tuberosity healing, which is historically unreliable in this age group.

Question 98

A 30-year-old male weightlifter felt a distinct "pop" in his anterior axilla while bench pressing. Examination reveals loss of the normal anterior axillary fold contour and weakness in internal rotation. MRI confirms a sternal head avulsion of the pectoralis major from the humerus. What is the recommended treatment?

Explanation

Acute surgical repair is recommended for active patients with pectoralis major ruptures, particularly sternal head avulsions from the humerus. Early repair restores strength and cosmetic appearance while minimizing the risk of difficult, chronically retracted reconstructions.

Question 99

A 40-year-old male presents with the acute onset of severe, unrelenting left shoulder pain that lasted for 10 days. The pain is now improving, but he has suddenly developed profound weakness in shoulder abduction and external rotation. He denies any trauma. What is the most appropriate next step in confirming the diagnosis?

Explanation

The classic clinical triad of severe acute pain followed by rapid improvement in pain and subsequent patchy weakness is highly suggestive of Parsonage-Turner syndrome (acute brachial neuritis). Diagnosis is confirmed by EMG/NCS, which will show denervation patterns without compressive etiology.

Question 100

A 32-year-old construction worker presents with persistent shoulder pain 8 months after sustaining a Type V acromioclavicular (AC) joint separation. Nonoperative management has failed to provide relief. What is the most appropriate surgical intervention?

Explanation

For symptomatic, chronic, high-grade AC joint separations (Type IV-VI or failed Type III), anatomic CC ligament reconstruction using a graft (autograft or allograft) is indicated. Primary repair or unaugmented procedures have a high failure rate in the chronic setting due to poor tissue quality.

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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