Orthopedic Shoulder Board Review 2026: MCQs Part 4

Question 1

A 50-year-old electrician who is right-hand dominant has had right shoulder pain and stiffness after sustaining an electric shock 2 months ago. An AP radiograph obtained at the time of injury was considered negative, and the patient was diagnosed with a shoulder sprain. The patient now reports continued shoulder pain and restricted motion. AP and axillary radiographs and a CT scan are shown in Figures 41a through 41c. Management should consist of

Explanation

41b 41c Open reduction and transfer of the subscapularis and lesser tuberosity into the humeral head defect is the treatment of choice for chronic posterior dislocations in which the articular defect consists of 20% to 40% of the articular surfaces. Closed reduction can be used if the dislocation is recognized early and the articular defect is less than 20% of the articular surface. Humeral arthroplasty is reserved for patients with an articular defect that is greater than 45% to 50% of the head. 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 2

Figure 42 shows the radiograph of a 70-year-old woman who has had a painful near ankylosis of her dominant elbow for 1 year. Treatment should consist of

Explanation

The patient has arthritis and supracondylar nonunion of the elbow. Total elbow replacement has been shown to give almost immediate return of function as it can be performed while leaving the triceps intact and resecting the distal humerus fragment. Attempts at osteosynthesis are indicated in younger individuals with good joint surface. Resection arthroplasty yields poor function and is reserved as a salvage procedure. Ramsey ML, Morrey BF: Total elbow arthroplasty for nonunion and dysfunctional instability, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 655-661.

Question 3

A 72-year-old woman who was doing well after undergoing total shoulder arthroplasty for arthritis 4 months ago is suddenly unable to elevate her arm. Examination reveals 70 degrees of external rotation compared with 45 degrees on the uninvolved side, and she is unable to lift her hand off her lower back. Radiographs are shown in Figures 43a through 43c. Treatment should consist of

Explanation

43b 43c Results of treatment of subscapularis rupture are best when immediate repair is performed. When the cause of the anterior instability is the result of rupture of the subscapularis tendon and the component position is acceptable, revising the position of the component is unnecessary. Restoring the coracoacromial arch and subacromial decompression are related to superior instability and rotator cuff pathology, respectively, and would not correct the instability caused by subscapularis rupture. Moeckel BH, Altchek DW, Warren RF, Wickiewicz TL, Dines DM: Instability of the shoulder after arthroplasty. J Bone Joint Surg Am 1993;75:492-497.

Question 4

A 25-year-old man underwent a Putti-Platt repair for recurrent anterior dislocation of his right shoulder 9 months ago. He reports no further episodes of instability but continues to have severely restricted motion, with external rotation limited to less than 0 degrees with the arm at the side. He has pain at the ends of range of motion and restricted activities of daily living despite undergoing nearly 9 months of physical therapy. Radiographs of the shoulder show no arthritic changes. Management should now consist of

Explanation

Open release allows lengthening of the shortened subscapularis and is preferred when there are extra-articular contractures. Arthroscopic release, combined with the use of an interscalene catheter postoperatively, is an excellent treatment for capsular contractures but is contraindicated after procedures that result in extracapsular shortening (ie, Magnuson-Stack, Putti-Platt). Additional physical therapy or manipulation under anesthesia is not likely to be helpful. Shoulder hemiarthroplasty is contraindicated with normal articular surfaces, but prosthetic arthroplasty is sometimes necessary for arthritis associated with instability or overly tight instability repairs. Harryman DT II, Matsen FA III, Sidles JA: Arthroscopic management of refractory shoulder stiffness. Arthroscopy 1997;13:133-147. Warner JJ: Frozen shoulder: Diagnosis and management. J Am Acad Orthop Surg 1997;5:130-140. 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 5

A 43-year-old bus driver sustains a hyperextension injury to her arm and shoulder 4 months after undergoing an open Bankart repair. Examination reveals increased external rotation, anterior shoulder pain, and internal rotation weakness. Her examination also reveals the findings shown in Figure 44. What is the most likely diagnosis?

Explanation

An isolated tear of the subscapularis tendon has been noted as early as 1835 by Smith. In Gerber and associates' 1991 report of 16 men with an average age of 51 years, isolated subscapularis tendon rupture was often caused by a violent hyperextension injury. All patients reported pain anteriorly along with night pain. They also noted pain and weakness of the arm. The lift-off test is performed by having the patient lift the palm of the hand away from the small of the back. The patient must have sufficient internal rotation to allow this test to be performed. A subscapularis rupture is likely if the patient cannot perform the lift-off test. Hertel R, Ballmer FT, Lombert SM, Gerber C: Lag signs in the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg 1996;5:307-313. Gerber C, Krushell RJ: Isolated rupture of the tendon of the subscapularis muscle: Clinical features in 16 cases. J Bone Joint Surg Br 1991;73:389-394. Greis PE, Kuhn JE, Schultheis J, Hintermeister R, Hawkins R: Validation of the lift-off test and analysis of subscapularis activity during maximal internal rotation. Am J Sports Med 1996;24:589-593.

Question 6

Radial nerve palsy is most commonly associated with which of the following types of humeral fractures?

Explanation

Although the Holstein-Lewis fracture, described as an oblique distal one third fracture, is best known for its association with neurologic injury, radial nerve palsy is most commonly associated with middle one third humeral fractures. Most nerve injuries are neurapraxias or axonotmeses, with up to 90% resolving in 3 to 4 months. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.

Question 7

A 30-year-old firefighter sustained a longitudinal pulling injury to the arm while attempting to move a heavy object during a fire. Figure 45 shows an MRI scan of the elbow. Initial management should consist of

Explanation

Because the MRI scan shows a complete rupture of the distal biceps tendon, the preferred treatment is anatomic repair of the tendon to the radial tuberosity either with the use of suture anchors or transosseous sutures through a two-incision technique. Several studies have documented superior results with anatomic repair of the distal biceps tendon when compared with results of nonsurgical management or repair of the tendon by attachment to the brachialis muscle. Patients undergoing anatomic repair of the distal biceps tendon through a two-incision technique typically regain a functional range of motion and nearly normal strength. D'Alessandro DF, Shields CL Jr, Tibone JE, Chandler RW: Repair of distal biceps tendon ruptures in athletes. Am J Sports Med 1993;21:114-119. Boyd JB, Anderson LD: A method for reinsertion of the distal biceps brachii tendon. J Bone Joint Surg Am 1961;43:1041-1043. Morrey BF, Askew LJ, An KN, Dobyns JH: Rupture of the distal tendon of the biceps brachii: A biomechanical study. J Bone Joint Surg Am 1985;67:418-421.

Question 8

Which of the following is considered a reasonable goal for arthroplasty surgery in rotator cuff arthropathy?

Explanation

Absence of the rotator cuff results in superior migration of the humeral head because of unopposed deltoid function. This proximal migration results in eccentric loading of glenoid components with early loosening. Hemiarthroplasty yields good pain relief with limited goals of active elevation of 90 degrees. The coracoacromial arch should be preserved. Achieving satisfactory subscapularis tension is preferred to the use of an oversized humeral component. Zeman CA, Arcand MA, Cantrell JS, Skedros JG, Burkhead WZ Jr: The rotator cuff-deficient arthritic shoulder: Diagnosis and surgical management. J Am Acad Orthop Surg 1998;6:337-348. Arntz CT, Jackins S, Matsen FA III: Prosthetic replacement of the shoulder for the treatment of defects in the rotator cuff and the surface of the glenohumeral joint. J Bone Joint Surg Am 1993;75:485-491. Williams GR Jr, Rockwood CA Jr: Hemiarthroplasty in rotator cuff-deficient shoulders. J Shoulder Elbow Surg 1996;5:362-367.

Question 9

What is the best surgical approach for the scapular fracture shown in Figure 46?

Explanation

Indications for open reduction of glenoid intra-articular fractures include those fractures with a 5-mm articular surface displacement or when the humeral head is subluxated with the fracture fragment. Kavanaugh and associates and Leung and Lam have shown that the posterior approach with plate fixation is best for most glenoid fractures, including the Ideberg type II fracture shown here. The anterior approach is best used for anterior rim and transverse fractures. Kavanagh BF, Bradway JK, Cofield RH: Open reduction and internal fixation of displaced intra-articular fractures of the glenoid fossa. J Bone Joint Surg Am 1993;75:479-484. Leung KS, Lam TP: Open reduction and internal fixation of ipsilateral fractures of the scapular neck and clavicle. J Bone Joint Surg Am 1993;75:1015-1018.

Question 10

Management of a grade IV osteochondritis dissecans lesion of the capitellum should consist of

Explanation

Osteochondritis dissecans of the capitellum is seen most commonly in adolescent athletes. It should be distinguished from osteochondrosis of the capitellum (Panner's disease), a self-limiting condition seen in younger patients. Lesions are graded I through V based on radiographic and arthroscopic appearance. Grade I lesions show intact but soft cartilage. Grade II lesions show fissuring of the overlying cartilage. Grade III lesions show exposed bone or an attached osteoarticular flap that is not loose. Grade IV lesions show a loose but nondisplaced osteoarticular flap. Grade V lesions show a displaced fragment. Simple excision of the loose osteoarticular flap is the treatment of choice for grade IV and V lesions. More complex procedures such as drilling of the in situ lesion, bone grafting, or internal fixation are associated with significantly worse results. While some authors advocate abrasion chondroplasty, the long-term benefits of the procedure are yet to be proven. Baumgarten TE: Osteochondritis dissecans of the capitellum. Sports Med Arthroscopy Rev 1995;3:219-223.

Question 11

What preoperative factor correlates best with the outcome of rotator cuff repair?

Explanation

The size of the rotator cuff tear in both anteroposterior and mediolateral dimensions has been found to correlate best with outcome. Older patient age and rupture of the long head of the biceps tend to be associated with larger tears and, therefore, may be associated indirectly with a poorer outcome. Iannotti JP: Full-thickness rotator cuff tears: Factors affecting surgical outcome. J Am Acad Orthop Surg 1994;2:87-95.

Question 12

A 55-year-old woman with polyarticular rheumatoid arthritis has had progressively increasing left shoulder pain for the past 2 years despite nonsurgical management. No focal weakness is noted during examination of the shoulder. AP and axillary radiographs are shown in Figures 47a and 47b. Treatment should consist of

Explanation

47b Unconstrained total shoulder arthroplasty has been found to yield satisfactory results in a high percentage of patients with rheumatoid involvement of the glenohumeral joint. Pain relief has been more predictable with total shoulder arthroplasty than humeral arthroplasty, and a glenoid component is favored when there is sufficient glenoid bone stock and an intact rotator cuff. Constrained or fixed-fulcrum devices have an unacceptably high failure rate because of loosening. Glenohumeral arthrodesis is avoided when the deltoid or rotator cuff is functioning because the functional results after arthroplasty are superior when compared with results of arthrodesis. Arthroscopic synovectomy may be helpful in early stages of the disease before extensive cartilage damage has occurred. Boyd AD Jr, Thomas WH, Scott RD, Sledge CB, Thornhill TS: Total shoulder arthroplasty versus hemiarthroplasty: Indications for glenoid resurfacing. J Arthroplasty 1990;5:329-336.

Question 13

When elevating the arm, the ratio of scapulothoracic to glenohumeral motion over the total range of motion is best described as

Explanation

The ratio of scapulothoracic to glenohumeral motion with elevation has been shown to vary depending on what portion of elevation is examined, how much load is on the arm, and the technique used to measure increments of elevation. However, almost every study shows that the ratio of scapulothoracic to glenohumeral motion is 1:2 for the contributions over a full range of elevation to 170 degrees. In the first 30 degrees of elevation, there is significant variability in the ratio, and there may be significant variability up to around 60 degrees. Inman VT, Saunders JR, Abbott LC: Observations of the function of the shoulder joint. Clin Orthop 1996;330:3-12.

Question 14

Figure 48 shows the initial AP chest radiograph of a 21-year-old motorcycle rider who sustained multiple injuries after striking a telephone pole at high speed. What is the most significant radiographic finding leading to a diagnosis?

Explanation

Scapulothoracic dissociation is a rare, violent traumatic injury in which the scapula is torn away from the chest wall but the skin remains intact. Massive swelling and ecchymosis are common. Neurovascular injury is the rule with possible subclavian or axillary artery disruption and severe partial or complete brachial plexus paralysis. The diagnosis is made on a nonrotated chest radiograph that shows significant lateral displacement of the medial scapular border from the sternal notch. A right midshaft clavicular fracture is present but is not considered the most significant finding. Ebraheim NA, An HS, Jackson WT, et al: Scapulothoracic dissociation. J Bone Joint Surg Am 1988;70:428-432. Ebraheim NA, Pearlstein SR, Savolaine ER, et al: Scapulothoracic dissociation. J Orthop Trauma 1987;1:18-23. Sampson LN, Britton JC, Eldrup-Jorgensen J, et al: The neurovascular outcome of scapulothoracic dissociation. J Vasc Surg 1993;17:1083-1088.

Question 15

A 21-year-old man who underwent repair of a distal biceps tendon rupture using a two-incision approach 4 months ago now reports difficulty gaining rotation of his forearm. Figures 49a and 49b show the AP and lateral radiographs. What is the most likely cause of his problem?

Explanation

49b The radiographs show early ectopic bone formation originating between the ulna and the radius. The development of ectopic bone in this area following a two-incision approach for anatomic repair of the distal biceps tendon is thought to be related to exposure of the periosteum of the lateral ulna during surgery. This can be avoided by the use of a muscle-splitting incision between the extensor carpi ulnaris and common extensor muscles. Full pronation of the forearm allows for the necessary exposure of the radial tuberosity during the procedure and for fixation of the tendon at its maximal length. Morrey BF: Tendon injuries about the elbow, in Morrey BF (ed): The Elbow and Its Disorders, ed. 2. Philadelphia, PA, WB Saunders, 1993, pp 492-503.

Question 16

A 53-year-old man reports acute, severe left shoulder pain after undergoing abdominal surgery 10 days ago. Initial management, consisting of anti-inflammatory drugs, physical therapy, and a subacromial injection of corticosteroid, fails to provide relief. Reexamination of the shoulder 2 months after the onset of symptoms reveals atrophy of the infraspinous and supraspinous fossa and profound weakness of active abduction and external rotation. His neck is supple with a full range of motion. Plain radiographs and an MRI scan of the shoulder are normal. What diagnostic study should be performed next in the evaluation of this patient?

Explanation

Suprascapular nerve palsy is a fairly uncommon yet well-known cause of shoulder pain and weakness. A variety of causes have been described, including compression by a ganglion cyst, an anomalous or thickened superior transverse scapular ligament, a humeral and scapular fracture, and traction or kinking of the nerve in the suprascapular notch. In this patient, the injury is most likely caused by traction or compression of the nerve in the suprascapular notch as the result of positioning during abdominal surgery; therefore, the studies of choice are electromyography and nerve conduction velocity studies. While MRI of the cervical spine may be of some value in ruling out a radiculopathy, the clinical history does not support such a cause for this condition. Rengachary SS, Neff JP, Singer PA, Brackett CE: Suprascapular entrapment neuropathy: A clinical, anatomical, and comparative study. Part 1: Clinical study. Neurosurgery 1979;5:441-446. Rengachary SS, Burr D, Lucas S, Hassanein KM, Mohn MP, Matzke H: Suprascapular entrapment neuropathy: A clinical, anatomical and comparative study. Part 2: Anatomical study. Neurosurgery 1979;5:447-451.

Question 17

A 58-year-old reports pain and stiffness in his left shoulder following a seizure episode. Diagnosis at the time of the seizure is a frozen shoulder, and management consists of an aggressive physical therapy program of stretching exercises. Four months later he continues to have shoulder pain and has not gained any additional range of motion. A CT scan is shown in Figure 50. Management should now consist of

Explanation

Humeral arthroplasty is indicated for chronic posterior dislocations when the impression defect in the humeral head is greater than 45% to 50%. If the condition remains undiagnosed for more than 9 to 12 months, secondary degenerative changes on the glenoid may occur, necessitating total shoulder arthroplasty. Open reduction and transfer of the subscapularis and lesser tuberosity are used for impression defects that consist of 20% to 40% of the humeral articular surface. Closed reduction and immobilization with the arm in slight extension and external rotation is useful when the posterior dislocation is diagnosed within the first 6 weeks and the articular defect is less than 20%. 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 18

When conducted at near physiologic strain rates, tensile studies of the inferior glenohumeral ligament (IGHL) have shown that the

Explanation

Tensile testing of the inferior glenohumeral ligament at near physiologic strain rates has shown that the anterior band of the IGHL has the greatest stiffness of the three ligament regions and the glenoid insertion site shows greater strain than the ligament midsubstance. Bigliani LU, Pollock RG, Soslowsky LJ, Flatow EL, Pawluk RJ, Mow VC: Tensile properties of the inferior glenohumeral ligament. J Orthop Res 1992;10:187-197.

Question 19

Manipulation under anesthesia for resistant frozen shoulder should be avoided in patients with

Explanation

Severe osteoporosis is a contraindication to manipulation under anesthesia in patients with a resistant frozen shoulder because of the higher risk of humeral fracture. Manipulation is considered for frozen shoulder in patients who are symptomatic despite undergoing a reasonable course of appropriate physical therapy. Harryman DT II: Shoulder: Frozen and stiff. Instr Course Lect 1997;42:247-257.

Question 20

A patient who sustained a cerebrovascular accident (CVA) 18 months ago has a long-standing spastic adduction contracture of the shoulder with a rigid block to passive external rotation. Significant hygiene problems exist with maceration and continued skin breakdown. Management should consist of

Explanation

Following a CVA, the muscular imbalance often leads to a fixed contracture of the shoulder in adduction, internal rotation, and flexion. The responsible muscles include the pectoralis major, subscapularis, teres major, and latissimus dorsi. If stretching cannot produce enough improvement for axillary hygiene, then surgery is an option. If the shoulder resists external rotation during examination with the arm at the side, as in this patient, then the subscapularis is spastic and contributing to the deformity as well and needs to be released along with the pectoralis. Phenol nerve blocks are most effective and best given within 6 months of the initial CVA to be effective. Lidocaine blocks may be helpful in determining whether a deformity is caused by a fixed soft-tissue contracture or by spasticity but play no role once the contracture is present. The modified L'Episcopo procedure is indicated in patients with contracture secondary to brachial plexus birth palsies. Braun RM, Botte MJ: Treatment of shoulder deformity in acquired spasticity. Clin Orthop 1999;368:54-65.

Question 21

A patient with degenerative osteoarthritis of the sternoclavicular (SC) joint reports constant pain, discomfort, and marked prominence and instability of the SC joint following medial clavicle resection. Which of the following procedures is most likely to produce these signs and symptoms?

Explanation

Medial clavicle excision alone can be associated with postoperative instability of the clavicle. The clavicle should be stabilized to the first rib by reconstructing the costoclavicular ligament if it is torn or if the resection is lateral to its clavicular insertion. Therefore, care must be taken to resect only that part of the clavicle that is medial to the costoclavicular ligament. Adequate protection for vital structures that lie posterior to the medial end of the clavicle must be provided. Bremner RA: Nonarticular noninfected subacute arthritis of the sternoclavicular joint. J Bone Joint Surg Br 1959;41:749-753.

Question 22

A 26-year-old man has had a 2-year history of pain and stiffness after sustaining a comminuted olecranon fracture. Treatment at the time of injury consisted of open reduction and internal fixation with tension band wiring. Examination reveals motion of 45 degrees to 110 degrees and pain throughout the arc of motion. Resisted flexion and extension are painful. Forearm rotation is normal. Radiographs are shown in Figure 51. Treatment should consist of

Explanation

The patient has posttraumatic arthritis of the elbow; therefore, the treatment of choice is hardware removal and soft-tissue releases with splinting to avoid recurrence of contractures. The combination of pain and stiffness in an elbow that has sustained significant joint surface damage renders it unresponsive to simple soft-tissue releases and heterotopic bone excision. Joint distraction and interposition arthroplasty offer the possibility of maintaining motion and relieving pain as a later salvage procedure. Joint replacement should not be performed in young, active, strong individuals because the prosthesis will fail quickly and complications will develop. Synovectomy and radial head excision are not indicated. Morrey BF: Distraction arthroplasty: Clinical applications. Clin Orthop 1993;293:46-54.

Question 23

What is the most common cause of rotator cuff injury in high school athletes?

Explanation

A large number of etiologies of rotator cuff injury have been proposed. Both intrinsic and extrinsic mechanisms have been suggested. In the young athlete the common underlying mechanism is overuse. Contributing factors include increased laxity, anatomic variation in the coracoacromial arch, and altered kinematics. Wilkins KE: Shoulder injuries: Epidemiology, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine. Philadelphia, PA, WB Saunders, 1994, pp 175-182.

Question 24

A 16-year-old boy with osteochondritis dissecans of the capitellum has intermittent symptoms of catching and locking. Examination is unremarkable. Radiographs reveal a loose body anteriorly with a diameter of 10 mm. To remove the loose body, elbow arthroscopy is being considered. Which of the following procedures would minimize the risk of neurovascular complication during the procedure?

Explanation

Complications of elbow arthroscopy are usually minor or temporary. However, serious complications include nerve injuries. The deep radial nerve is the closest to any of the portals, resting as close as 1 mm away from the scope inserted in the anterolateral portal. The capsule can be displaced anteriorly by distending the joint with about 25 mL of saline solution, thus moving the deep radial nerve approximately 1 cm anteriorly and decreasing the risk of injuring it while establishing the anterolateral portal. Keeping plastic cannulae in the portals may help to diminish fluid extravasation and swelling, which is more of an impediment than a serious complication. The image intensifier has no documented role in guiding loose body removal. While the proximal anteromedial portal is probably the safest anterior portal to establish, it is actually easier to remove a large loose body from this portal while viewing it from an anterolateral position. There is less tendon and muscle bulk to pass through at the site of the proximal anteromedial portal than at the anterolateral portal, making it less likely for the loose body to get stuck in the soft tissues. Techniques have been developed to permit removal of loose bodies as large as 2 cm in diameter without breaking them up into pieces. If it is possible to remove a large loose body intact, doing so greatly simplifies and shortens the procedure. Lynch GJ, Meyers JF, Whipple TL, Caspari RB: Neurovascular anatomy and elbow arthroscopy: Inherent risks. Arthroscopy 1986;2:190-197.

Question 25

Examination of the shoulder seen in Figure 52 shows atrophy and tenderness of the infraspinous fossa and profound weakness in external rotation. The supraspinous fossa shows normal muscle bulk. What is the most likely cause of this condition?

Explanation

Compression of the suprascapular nerve by a ganglion cyst is a well-documented cause of pain and weakness in the shoulder. Isolated involvement of the infraspinatus indicates that the area of entrapment is at the spinoglenoid notch and not the suprascapular notch. The majority of ganglion cysts found in the shoulder are related to tears of the labrum. When such a compressive lesion is found, decompression can be accomplished through either an open or arthroscopic approach. Several authors have shown the value of arthroscopy in the treatment of this condition. It has been shown that it is technically possible to decompress a paralabral ganglion cyst using arthroscopy; this method is usually followed by repair of the torn labrum. Alternatively, arthroscopic repair of the labrum can be performed and the cyst may be aspirated at the time of surgery. Open cyst excision through a posterior approach is also an acceptable method of treatment. Schickendantz MS, Ho CP: Suprascapular nerve compression by a ganglion cyst: Diagnosis by magnetic resonance imaging. J Shoulder Elbow Surg 1993;2:110-114. Thompson RC, Schneider W, Kennedy T: Entrapment neuropathy of the inferior branch of the suprascapular nerve by ganglia. Clin Orthop 1982;166:185-187.

Question 26

A 45-year-old man presents to the emergency department after a first-time seizure. He is unable to externally rotate his right arm. Radiographs reveal a posterior shoulder dislocation with an anteromedial humeral head defect involving 30% of the articular surface. Closed reduction is successful, but the shoulder remains unstable in internal rotation. What is the most appropriate definitive management?

Explanation

For a reverse Hill-Sachs lesion involving 20% to 40% of the articular surface, a lesser tuberosity transfer (McLaughlin procedure or its modification) is the treatment of choice to prevent the defect from engaging. Defects >40% typically require arthroplasty.

Question 27

A 28-year-old weightlifter presents with right shoulder pain and weakness. On physical examination, the inferior angle of the right scapula is translated laterally and superiorly when the patient pushes against a wall. Which of the following nerves is most likely injured?

Explanation

Lateral scapular winging is caused by trapezius muscle paralysis resulting from a spinal accessory nerve injury. Medial winging is caused by serratus anterior paralysis due to a long thoracic nerve injury.

Question 28

A 32-year-old professional volleyball player presents with posterior shoulder pain and weakness in external rotation. Forward elevation and internal rotation strength are normal. MRI demonstrates an isolated paralabral cyst at the spinoglenoid notch. Which physical examination finding is most likely present?

Explanation

Compression of the suprascapular nerve at the spinoglenoid notch affects only the motor branch to the infraspinatus. This leads to isolated infraspinatus atrophy and weakness in external rotation, sparing the supraspinatus.

Question 29

A 72-year-old woman with a history of a massive, retracted, irreparable rotator cuff tear presents with worsening shoulder pain and an inability to actively elevate her arm past 40 degrees. Her passive elevation is 150 degrees. Radiographs show superior migration of the humeral head with an acromiohumeral distance of 3 mm. What is the most reliable surgical option?

Explanation

Reverse total shoulder arthroplasty is the most reliable and effective treatment for elderly patients with pseudoparalysis and rotator cuff tear arthropathy. Biologic reconstructions and tendon transfers have high failure rates in this demographic.

Question 30

A 35-year-old male bodybuilder feels a pop in his anterior chest while performing a heavy bench press. He has bruising and a palpable defect medially on the humerus. MRI confirms a complete tear of the pectoralis major tendon at its insertion. Which head of the pectoralis major typically tears first, and where does it insert relative to the other head?

Explanation

The sternal head of the pectoralis major is placed under the most tension during extreme extension and external rotation (bench press) and typically tears first. The tendon twists 180 degrees, causing the sternal head to insert posterior and superior to the clavicular head.

Question 31

A 65-year-old woman sustained a 3-part proximal humerus fracture. Open reduction and internal fixation with a locking plate was performed. At 3-month follow-up, radiographs demonstrate varus collapse of the humeral head and intra-articular screw penetration. What is the most critical technical factor at the time of index surgery to prevent this complication?

Explanation

Loss of medial column support leads to varus collapse after proximal humerus fracture fixation. Placement of an inferomedial calcar screw into the inferomedial quadrant of the humeral head provides structural support and significantly reduces this risk.

Question 32

A 22-year-old rugby player has recurrent anterior shoulder dislocations. CT scan with 3D reconstruction reveals 25% anterior glenoid bone loss. A Latarjet procedure is performed. Which of the following structures creates the 'sling effect' stabilizing the shoulder in abduction and external rotation after this procedure?

Explanation

The Latarjet procedure transfers the coracoid process along with the attached conjoined tendon. The conjoined tendon acts as a dynamic sling over the lower subscapularis and anteroinferior capsule when the arm is abducted and externally rotated.

Question 33

A 68-year-old man who underwent an anatomic total shoulder arthroplasty 6 weeks ago reports sudden onset of anterior shoulder pain and increased weakness after reaching for a heavy door. On examination, he has increased passive external rotation and a positive bear-hug test.

Radiographs are unremarkable. What is the most likely diagnosis?

Explanation

Sudden pain, increased passive external rotation, and weakness in internal rotation (positive bear-hug test) in the early postoperative period after TSA are classic signs of subscapularis failure. This requires prompt diagnostic imaging and likely surgical repair.

Question 34

A 45-year-old recreational tennis player has deep shoulder pain with overhead serving. MRI shows a Type II SLAP tear. He has failed 6 months of physical therapy. What is the most appropriate surgical treatment for this patient given his age and activity profile?

Explanation

In patients older than 40 years, biceps tenodesis has been shown to yield better functional outcomes, better pain relief, and lower revision rates compared to arthroscopic SLAP repair for Type II SLAP lesions.

Question 35

A 55-year-old man presents with severe glenohumeral osteoarthritis. CT scan shows a Walch type B2 glenoid with 20 degrees of retroversion and posterior humeral head subluxation. What is the most appropriate strategy for addressing the glenoid deformity if an anatomic total shoulder arthroplasty is planned?

Explanation

For a B2 glenoid with >15 degrees of retroversion, excessive asymmetric reaming removes critical subchondral bone, increasing the risk of component subsidence. The preferred strategy is partial correction (up to 10 degrees) paired with a posteriorly augmented component or bone graft.

Question 36

A 28-year-old cyclist fell onto his shoulder point. Radiographs reveal a Type III acromioclavicular (AC) joint injury (100% superior translation of the clavicle). What is the consensus regarding initial management?

Explanation

The initial management for uncomplicated Type III AC joint injuries is nonoperative, focusing on brief sling immobilization and early range of motion. Surgery is generally reserved for patients who remain symptomatic after conservative care.

Question 37

A 21-year-old collegiate baseball pitcher complains of posterior shoulder pain during the late cocking phase of throwing. He has a positive posterior impingement sign and GIRD (glenohumeral internal rotation deficit) of 25 degrees. What is the primary pathophysiologic mechanism of this condition?

Explanation

Internal impingement typically occurs in overhead athletes during the late cocking phase (extreme abduction and external rotation). It involves the mechanical pinching of the articular-sided posterosuperior rotator cuff between the greater tuberosity and posterosuperior glenoid labrum.

Question 38

A 22-year-old collegiate baseball pitcher presents with vague posterior right shoulder pain. Physical examination reveals glenohumeral internal rotation of 25 degrees and external rotation of 135 degrees on the right, compared to 65 degrees of internal rotation and 95 degrees of external rotation on the left. Radiographs are normal. What is the most appropriate initial management?

Explanation

This patient exhibits Glenohumeral Internal Rotation Deficit (GIRD). The initial treatment of choice is a dedicated physical therapy program focusing on posteroinferior capsular stretching, such as the sleeper stretch.

Question 39

In reverse total shoulder arthroplasty (RTSA), changing the center of rotation alters the biomechanical advantage of the deltoid muscle. Which of the following best describes the kinematic changes associated with a Grammont-style RTSA design compared to the native shoulder?

Explanation

The Grammont-style RTSA medializes and distalizes (inferiorly translates) the center of rotation. This increases the deltoid moment arm, recruiting more deltoid fibers to power forward elevation.

Question 40

A 55-year-old active manual laborer presents with chronic shoulder pain and weakness. MRI demonstrates a massive, retracted, and irreparable tear of the supraspinatus and infraspinatus with advanced fatty infiltration (Goutallier stage 4). The subscapularis and teres minor are completely intact. He has a positive external rotation lag sign. Which of the following surgical interventions is most appropriate?

Explanation

Latissimus dorsi transfer is indicated for younger, active patients with massive, irreparable posterosuperior rotator cuff tears and an intact subscapularis. It effectively restores active external rotation and forward elevation.

Question 41

A 40-year-old man undergoes shoulder arthroscopy for chronic anterior shoulder pain. Intraoperatively, the long head of the biceps tendon is found to be medially subluxated out of the bicipital groove. This finding is most strongly associated with a tear of which of the following structures?

Explanation

Medial subluxation of the long head of the biceps tendon is highly associated with a tear of the subscapularis tendon and disruption of the coracohumeral ligament, which together form the medial sling of the biceps pulley.

Question 42

A 70-year-old woman presents with persistent shoulder pain 1 year after a reverse total shoulder arthroplasty.

Radiographs show inferior scapular notching. What is the most critical factor during baseplate implantation to minimize this complication?

Explanation

Inferior overhang of the glenosphere beyond the inferior glenoid rim and an inferior tilt help minimize scapular notching in reverse total shoulder arthroplasty. Medialization and superior tilt increase the risk of this complication.

Question 43

A 24-year-old male presents with right shoulder pain and weakness after carrying a heavy backpack during a 3-week hike. On exam, he has medial scapular winging when pushing against a wall. Which of the following nerve-muscle combinations is affected?

Explanation

Medial scapular winging is caused by paralysis of the serratus anterior, which is innervated by the long thoracic nerve. Trapezius palsy secondary to spinal accessory nerve injury typically causes lateral winging.

Question 44

A 65-year-old woman sustains a 3-part proximal humerus fracture involving the surgical neck and greater tuberosity.

If an open reduction and internal fixation (ORIF) is performed, what is the most important radiographic predictor of postoperative avascular necrosis of the humeral head?

Explanation

Disruption of the medial calcar hinge significantly increases the risk of avascular necrosis. It indicates severe soft-tissue and periosteal stripping, jeopardizing the blood supply from the circumflex humeral vessels.

Question 45

A 21-year-old rugby player undergoes a Latarjet procedure for recurrent anterior shoulder instability with 25% glenoid bone loss. Postoperatively, he exhibits profound weakness in elbow flexion and supination, along with sensory loss over the lateral forearm. Which nerve was most likely injured during the procedure?

Explanation

The musculocutaneous nerve is at high risk during the Latarjet procedure due to its proximity to the coracoid and conjoint tendon. Injury leads to weak biceps and brachialis muscles and numbness in the lateral antebrachial cutaneous nerve distribution.

Question 46

A 55-year-old laborer has an irreparable posterosuperior rotator cuff tear with an intact subscapularis and no glenohumeral arthritis. He has intact forward elevation but profound weakness in external rotation and a positive Hornblower's sign. Which tendon transfer is most appropriate?

Explanation

Lower trapezius transfer is highly effective for restoring external rotation in patients with irreparable posterosuperior tears. Its vector closely matches that of the infraspinatus, making it superior to latissimus dorsi for restoring external rotation.

Question 47

A 22-year-old collegiate baseball pitcher complains of posterior shoulder pain during the late cocking phase of throwing. MRI arthrogram reveals a partial articular-sided supraspinatus tendon avulsion (PASTA) and a superior labral tear. Which of the following is the primary underlying pathomechanism?

Explanation

Internal impingement occurs when the hyper-externally rotated and abducted arm causes the greater tuberosity to abut the posterosuperior glenoid. This pinches the posterior rotator cuff and superior labrum, causing fraying and tears.

Question 48

Glenohumeral internal rotation deficit (GIRD) in overhead athletes is typically accompanied by which of the following capsular adaptations?

Explanation

GIRD is associated with a contracture of the posteroinferior capsule, which alters glenohumeral kinematics by pushing the humeral head posterosuperiorly during cocking. This increases stress on the superior labrum and posterior cuff.

Question 49

A 30-year-old cyclist falls directly onto his shoulder.

Radiographs show 150% superior displacement of the distal clavicle relative to the acromion. Which ligaments are disrupted?

Explanation

Displacement greater than 100% indicates a high-grade acromioclavicular joint injury (Type III or V). This requires complete disruption of both the acromioclavicular (AC) and coracoclavicular (CC) ligament complexes.

Question 50

A 52-year-old woman with poorly controlled type 2 diabetes presents with progressive shoulder stiffness and pain. Physical exam shows restricted active and passive motion in all planes. Which of the following is the most consistent histological finding in the affected tissue?

Explanation

Adhesive capsulitis (frozen shoulder) is characterized by fibroplasia. Histology demonstrates a dense proliferation of myofibroblasts and predominantly type III collagen deposition in the joint capsule, particularly at the rotator interval.

Question 51

A 60-year-old man falls on an outstretched arm and experiences anterior shoulder pain. He has a positive bear-hug test and increased passive external rotation compared to the contralateral side.

What other structure is most commonly injured with this specific tendon tear?

Explanation

The subscapularis is crucial for stabilizing the long head of the biceps in the bicipital groove. Subscapularis tears are highly associated with biceps subluxation, dislocation, or tearing.

Question 52

A 68-year-old man presents with vague shoulder pain 2 years after an anatomic total shoulder arthroplasty. Inflammatory markers (CRP, ESR) are normal, and aspiration yields no growth at 3 days. What is the most appropriate next step in diagnosing a potential Cutibacterium acnes infection?

Explanation

Cutibacterium acnes is an indolent, slow-growing anaerobic organism commonly responsible for late shoulder arthroplasty infections. Cultures must be held for at least 14 to 21 days to maximize detection yield.

Question 53

A 19-year-old football player sustains a posterior sternoclavicular dislocation after being tackled. He complains of mild difficulty swallowing. What is the most appropriate initial management step?

Explanation

Posterior sternoclavicular dislocations can compress vital mediastinal structures such as the trachea, esophagus, or great vessels. Urgent closed reduction in the OR under general anesthesia with cardiothoracic surgery on standby is the standard of care.

Question 54

A 35-year-old motorcyclist is involved in a high-speed collision.

He presents with a massive shoulder hematoma, absent radial pulse, and a completely flail extremity. Chest radiograph shows lateral displacement of the scapula. What is the most common neurologic injury associated with this condition?

Explanation

Scapulothoracic dissociation involves complete disruption of the scapulothoracic articulation. It is a high-energy trauma highly associated with devastating injuries, most commonly a complete brachial plexus avulsion and vascular disruption.

Question 55

A 42-year-old man presents with sudden onset of severe, unrelenting right shoulder pain lasting for 2 weeks, followed by profound weakness in overhead elevation and external rotation as the pain subsides.

MRI of the shoulder is unremarkable. What is the most likely diagnosis?

Explanation

Parsonage-Turner syndrome typically presents with an acute phase of severe, debilitating shoulder pain. This is followed by a painless phase characterized by patchy weakness and profound atrophy of shoulder girdle muscles due to brachial neuritis.

Question 56

A 28-year-old weightlifter feels a "pop" and burning pain in his anterior axillary fold while performing a heavy bench press. Exam reveals loss of the anterior axillary contour and weakness in internal rotation. Which portion of the pectoralis major is most commonly ruptured in this scenario?

Explanation

Pectoralis major ruptures during bench pressing typically involve the sternocostal head, which is placed under maximum tension at the bottom of the lift. The clavicular head often remains intact.

Question 57

A 26-year-old female presents with a painful clunking sensation at the superomedial angle of her scapula during arm elevation. Nonoperative management has failed. Which bony structure may need resection to relieve her symptoms?

Explanation

Snapping scapula syndrome often involves bursitis or bony abnormalities at the superomedial border of the scapula. If prolonged conservative treatment fails, partial resection of the superomedial angle provides significant relief.

Question 58

A 55-year-old man sustains an anterior shoulder dislocation. Post-reduction radiographs show a reduced joint but a displaced greater tuberosity fracture that is migrated 8 mm superiorly. What is the most appropriate management?

Explanation

Superior displacement of the greater tuberosity greater than 5 mm leads to severe subacromial impingement and altered rotator cuff biomechanics. Surgical fixation is required to restore normal function.

Question 59

A 55-year-old active male presents with a massive, irreparable posterosuperior rotator cuff tear. He has an intact subscapularis, a Hamada grade 1 shoulder on radiographs, and good deltoid function. He undergoes a superior capsular reconstruction (SCR). What is the primary biomechanical goal of this procedure?

Explanation

Superior capsular reconstruction (SCR) acts as a static restraint to prevent superior migration of the humeral head in massive irreparable rotator cuff tears. This helps to center the humeral head within the glenoid, improving the efficiency of the intact deltoid and force couples.

Question 60

To minimize the risk of scapular notching following a reverse total shoulder arthroplasty (RTSA), how should the glenosphere component optimally be positioned on the baseplate?

Explanation

Scapular notching in RTSA is caused by the humeral component impinging on the inferior scapular neck. Inferior tilt and inferior positioning (or eccentric offset) of the glenosphere move the center of rotation downward, reducing this mechanical impingement.

Question 61

A 45-year-old manual laborer undergoes an open subpectoral biceps tenodesis. In the recovery room, the patient complains of numbness over the lateral aspect of his forearm and profound weakness in elbow flexion. Which of the following nerves was most likely injured during the procedure?

Explanation

The musculocutaneous nerve is at risk during a subpectoral biceps tenodesis, particularly if retractors are placed too medially under the conjoined tendon. Injury results in biceps/brachialis weakness and numbness in the lateral antebrachial cutaneous nerve distribution.

Question 62

A 30-year-old cyclist falls directly onto his right shoulder. Radiographs demonstrate 150% superior displacement of the distal clavicle relative to the acromion, and the coracoclavicular distance is more than doubled compared to the contralateral side. What is the most appropriate management for this Rockwood Type V acromioclavicular (AC) joint injury?

Explanation

Rockwood Type V injuries involve severe superior displacement (>100%) due to disruption of both the AC and CC ligaments, along with stripping of the deltotrapezial fascia. Operative intervention (CC ligament reconstruction/fixation) is generally indicated for Type V injuries to restore mechanics and alleviate pain.

Question 63

A 55-year-old woman with poorly controlled type 1 diabetes mellitus presents with severe, progressive shoulder pain and stiffness over the past 4 months. Examination reveals global loss of active and passive range of motion, with external rotation limited to 10 degrees. Radiographs are normal. The pathophysiology of this condition is primarily characterized by fibroblastic proliferation and thickening of which capsular structures?

Explanation

Adhesive capsulitis (frozen shoulder) demonstrates significant fibroblastic proliferation, most notably in the rotator interval and the coracohumeral ligament. Contracture of the coracohumeral ligament is the primary reason for the pathognomonic loss of external rotation.

Question 64

A 65-year-old female sustains a displaced 3-part proximal humerus fracture after a ground-level fall. On examination, she has decreased pinprick sensation over the lateral aspect of her shoulder. Based on this neurologic deficit, what additional clinical finding is she most likely to exhibit once pain allows for strength testing?

Explanation

Decreased sensation over the lateral shoulder indicates an axillary nerve injury, which is the most common nerve injured in proximal humerus fractures. The axillary nerve innervates the deltoid (abduction) and the teres minor (external rotation).

Question 65

A 22-year-old collegiate baseball pitcher complains of posterior shoulder pain during the late cocking phase of throwing. Examination shows a significant glenohumeral internal rotation deficit (GIRD). MRI reveals an articular-sided partial tear of the posterior supraspinatus and anterior infraspinatus. What is the primary mechanical mechanism underlying this specific injury?

Explanation

This presentation is classic for internal impingement, which occurs in overhead throwers during the late cocking phase (abduction and maximal external rotation). It involves the abnormal abutment of the greater tuberosity against the posterosuperior glenoid, pinching the articular-sided rotator cuff.

Question 66

A 35-year-old woman presents with persistent shoulder pain and weakness 6 months after a posterior triangle cervical lymph node biopsy. Examination reveals lateral winging of the scapula and an inability to actively abduct the arm past 90 degrees. If nonoperative management fails, which tendon transfer procedure is most appropriate?

Explanation

Lateral winging of the scapula suggests spinal accessory nerve palsy leading to trapezius paralysis, often iatrogenic from posterior triangle neck surgery. The Eden-Lange procedure transfers the levator scapulae and rhomboids to the lateral scapula to replicate trapezius function.

Question 67

A 72-year-old male with a known chronic, massive rotator cuff tear presents with worsening shoulder pain. Plain radiographs show an acromiohumeral interval of 3 mm, acetabularization of the coracoacromial arch, and severe narrowing of the glenohumeral joint space with inferior osteophytes. According to the Hamada classification, what grade is this patient's rotator cuff tear arthropathy?

Explanation

The Hamada classification stages rotator cuff arthropathy: Grade 1 is AHI >6mm; Grade 2 is AHI <5mm; Grade 3 adds acetabularization of the acromion; Grade 4 features the addition of glenohumeral arthritis (joint space narrowing); Grade 5 includes humeral head collapse/necrosis.

Question 68

A 24-year-old rugby player presents after his fourth anterior shoulder dislocation. A 3D CT scan demonstrates 25% anterior glenoid bone loss and a deep, engaging Hill-Sachs lesion. Which of the following is the most appropriate surgical intervention to minimize the risk of recurrence?

Explanation

In the setting of recurrent anterior instability with critical anterior glenoid bone loss (typically >20-25%) and an engaging Hill-Sachs lesion, an isolated soft tissue repair has an unacceptably high failure rate. A bony augmentation procedure, such as the open Latarjet (coracoid transfer), is the gold standard.

Question 69

An 18-year-old male presents with a painful clunking and grating sensation beneath his right scapula with overhead movement. Physical therapy and injections have failed to provide relief. A CT scan of the chest and shoulder reveals a bony exostosis arising from the ventral surface of the scapula. What is the most likely underlying diagnosis?

Explanation

Snapping scapula syndrome in a young patient is commonly caused by an osteochondroma on the ventral surface of the scapula. Elastofibroma dorsi can also cause snapping but usually presents as a soft tissue mass in older patients (typically >50 years) located between the lower scapula and chest wall.

Question 70

A 28-year-old male bodybuilder felt a sudden 'pop' in his anterior axilla while performing heavy bench presses. Physical examination demonstrates the loss of the anterior axillary fold and weakness in internal rotation and adduction of the shoulder. MRI confirms a complete tear of the sternal head of the pectoralis major. Where does the majority of these ruptures anatomically occur?

Explanation

Pectoralis major ruptures, especially in weightlifters performing bench presses, most commonly occur at or near the tendon's insertion onto the humerus. Operative repair of the distal tendon insertion is highly successful and recommended in active individuals.

Question 71

A 65-year-old male with primary glenohumeral osteoarthritis undergoes surgical planning for a total shoulder arthroplasty. A preoperative CT scan demonstrates a Walch B2 glenoid with 20 degrees of retroversion and biconcave posterior wear. If a standard anatomic polyethylene glenoid component is implanted without correcting the version, what is the most likely mechanism of early component failure?

Explanation

A Walch B2 glenoid is characterized by posterior subluxation of the humeral head and biconcave wear. Failing to correct the severe retroversion leads to eccentric posterior loading on the new glenoid component, causing a 'rocking horse' effect and subsequent early aseptic loosening.

Question 72

A 32-year-old professional volleyball player presents with vague, deep posterior shoulder pain and weakness. Clinical examination reveals isolated atrophy of the infraspinatus fossa, while the supraspinatus bulk and strength are completely normal. She has notable weakness in external rotation. An MRI is obtained. At which of the following anatomic locations is a paralabral cyst most likely compressing the involved nerve?

Explanation

Isolated atrophy and weakness of the infraspinatus indicate compression of the suprascapular nerve distal to the innervation of the supraspinatus. This occurs at the spinoglenoid notch, often due to a paralabral cyst associated with a posterior SLAP tear.

Question 73

A 14-year-old elite adolescent baseball pitcher presents with generalized, progressive right shoulder pain during throwing over the past two months. He denies any acute traumatic event. Examination reveals tenderness over the lateral aspect of the proximal humerus but normal range of motion. Radiographs demonstrate widening, sclerosis, and irregularity of the proximal humeral physis. What is the most appropriate initial management?

Explanation

This presentation describes 'Little League Shoulder' (epiphysiolysis of the proximal humerus), an overuse injury in skeletally immature throwers. The mainstay of treatment is absolute rest from throwing (usually up to 3 months) to allow physeal healing, followed by a structured return-to-throwing program.

Question 74

A 70-year-old woman is scheduled to undergo a reverse total shoulder arthroplasty for cuff tear arthropathy. The Grammont-style reverse prosthesis changes the biomechanics of the shoulder joint to restore active elevation. Which of the following best describes this biomechanical alteration?

Explanation

The Grammont design principles for reverse total shoulder arthroplasty include medializing and distalizing the center of rotation. This increases the deltoid moment arm, converts shear forces to compressive forces at the glenoid, and allows the deltoid to compensate for a deficient rotator cuff.

Question 75

A 22-year-old professional rugby player presents with recurrent anterior shoulder instability. A 3D CT scan reveals 25% anterior glenoid bone loss. A Latarjet procedure is planned. During the approach, which muscle must be longitudinally split to access the glenohumeral joint?

Explanation

The Latarjet procedure involves transferring the coracoid process with the attached conjoined tendon to the anterior glenoid. This requires a longitudinal split of the subscapularis muscle (typically in its lower third) to expose the anterior glenohumeral joint and fix the graft.

Question 76

A 65-year-old man presents with progressive pain and stiffness 8 months after an anatomic total shoulder arthroplasty. Serum ESR and CRP are within normal limits. Joint aspiration is performed, and cultures are held for 14 days, eventually growing Cutibacterium acnes. Which of the following characterizes this organism?

Explanation

Cutibacterium acnes (formerly Propionibacterium acnes) is a slow-growing, Gram-positive, anaerobic (or microaerophilic) bacillus commonly found in the sebaceous glands of the shoulder. It is a frequent cause of indolent periprosthetic shoulder infections.

Question 77

A 28-year-old volleyball player presents with insidious onset of posterior shoulder pain and weakness in external rotation. Examination shows isolated atrophy of the infraspinatus fossa. The supraspinatus has normal bulk and strength. MRI is most likely to reveal a paralabral cyst in which of the following locations?

Explanation

A cyst at the spinoglenoid notch compresses the distal suprascapular nerve after it has already innervated the supraspinatus, leading to isolated infraspinatus atrophy and external rotation weakness. Compression at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 78

A 55-year-old laborer has a massive, irreparable posterosuperior rotator cuff tear. He maintains active forward elevation to 130 degrees but has severe external rotation lag. A latissimus dorsi tendon transfer is planned.

Which of the following is a primary contraindication to performing an isolated latissimus dorsi transfer in this patient?

Explanation

A latissimus dorsi transfer requires an intact and functional subscapularis tendon to provide an anterior force couple. If the subscapularis is torn and irreparable, the transferred latissimus will worsen anterior-superior escape, leading to failure.

Question 79

A 32-year-old bodybuilder feels a '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 tendon at its humeral insertion. Which of the following accurately describes the anatomy of this tendon?

Explanation

The pectoralis major tendon undergoes a 180-degree twist before inserting onto the lateral lip of the bicipital groove. The sternal head twists such that its fibers insert proximal and deep to the untwisted clavicular head fibers.

Question 80

In the evaluation of a displaced proximal humerus fracture, which of the following criteria described by Hertel is the strongest radiographic predictor of humeral head ischemia?

Explanation

Hertel's criteria for a high risk of avascular necrosis (ischemia) after proximal humerus fractures include a calcar length of less than 8 mm, disruption of the medial periosteal hinge, and an anatomic neck fracture pattern.

Question 81

A 21-year-old collegiate baseball pitcher presents with vague posterior shoulder pain during the late cocking phase of throwing. Physical examination reveals a 25-degree loss of glenohumeral internal rotation (GIRD) compared to the contralateral side. Pathologic contracture of which structure is primarily responsible for this physical exam finding?

Explanation

Glenohumeral internal rotation deficit (GIRD) in overhead throwers is classically driven by contracture and thickening of the posteroinferior capsule, specifically the posterior band of the inferior glenohumeral ligament (IGHL).

Question 82

A 26-year-old man presents with right shoulder pain and weakness 3 weeks after a viral illness. On examination, forward elevation is limited to 90 degrees, and there is prominent medial winging of the scapula when he pushes against a wall.

Which nerve is most likely affected, and what muscle does it innervate?

Explanation

Medial winging of the scapula is caused by paralysis of the serratus anterior muscle, which is innervated by the long thoracic nerve. Viral illness can trigger a neuritis (Parsonage-Turner syndrome) causing this palsy.

Question 83

A 48-year-old woman with type 1 diabetes presents with insidious onset of severe, diffuse shoulder pain and significant loss of active and passive range of motion. Histological analysis of the joint capsule in this condition is most likely to show which of the following?

Explanation

Adhesive capsulitis is characterized histologically by a fibroblastic proliferation and dense deposition of type III collagen (similar to Dupuytren's disease), driven by inflammatory cytokines such as TGF-beta.

Question 84

A 35-year-old man sustained a highly comminuted proximal humerus fracture and is scheduled for operative fixation. Postoperatively, he is noted to have a sensory deficit over the lateral aspect of his shoulder and weakness in external rotation.

Which space did the likely injured nerve pass through to innervate the affected muscle?

Explanation

The patient has an axillary nerve injury, causing lateral shoulder numbness and weakness of the teres minor (external rotation) and deltoid. The axillary nerve passes through the quadrilateral space along with the posterior circumflex humeral artery.

Question 85

A 19-year-old man presents to the trauma bay after a high-speed motor vehicle collision. He complains of shortness of breath and difficulty swallowing. His left clavicle is clinically absent medially. A CT scan confirms a posterior sternoclavicular dislocation. What is the most critical logistical step before attempting closed reduction?

Explanation

Posterior sternoclavicular dislocations can compress or tear the great vessels, trachea, or esophagus. Closed reduction should be performed in the operating room with a cardiothoracic surgeon available in case of catastrophic vascular injury during reduction.

Question 86

A 60-year-old man undergoes a lower trapezius tendon transfer augmented with an Achilles tendon allograft for a massive, irreparable posterosuperior rotator cuff tear.

What nerve supplies the transferred muscle, and what primary motion is restored?

Explanation

The lower trapezius transfer is primarily used to restore external rotation in patients with massive, irreparable posterosuperior rotator cuff tears. The trapezius is innervated by the spinal accessory nerve (Cranial Nerve XI).

Question 87

A 75-year-old man presents with chronic right shoulder pain and an inability to actively elevate his arm above 60 degrees, though passive elevation is 150 degrees. Radiographs demonstrate severe glenohumeral osteoarthritis with superior migration of the humeral head articulating with the acromion. Which of the following is the most appropriate surgical management?

Explanation

Reverse total shoulder arthroplasty is the treatment of choice for rotator cuff tear arthropathy with pseudoparalysis in the elderly. It shifts the center of rotation medially and inferiorly, recruiting the deltoid to effectively elevate the arm.

Question 88

A 22-year-old collegiate rugby player presents with recurrent anterior shoulder instability. A 3D CT scan reveals 25% anterior glenoid bone loss and an engaging Hill-Sachs lesion.

What is the most appropriate definitive management to minimize the risk of recurrent dislocation?

Explanation

Anterior glenoid bone loss exceeding 20-25% in a collision athlete is associated with unacceptably high failure rates following soft-tissue stabilization alone. The Latarjet procedure (coracoid transfer) provides both a bony block and a soft-tissue sling to reliably restore stability.

Question 89

A 45-year-old manual laborer presents with persistent anterior shoulder pain. He has a positive O'Brien test, and an MRI arthrogram reveals an isolated type II SLAP tear. After 6 months of failed nonoperative management, what is the most reliable surgical treatment?

Explanation

In middle-aged patients and manual laborers, biceps tenodesis provides more reliable pain relief and quicker return to work compared to SLAP repair. SLAP repairs in this demographic frequently lead to persistent pain and postoperative stiffness.

Question 90

A 55-year-old woman presents with 4 months of progressive, insidious onset right shoulder pain and stiffness. Physical examination shows significantly restricted active and passive external rotation with the arm at the side. Radiographs are normal. Which of the following systemic conditions is most strongly associated with this diagnosis and portends a more refractory clinical course?

Explanation

Adhesive capsulitis (frozen shoulder) has a strong association with diabetes mellitus, occurring in up to 20% of diabetic patients. These patients tend to have a more protracted and treatment-resistant clinical course compared to the idiopathic population.

Question 91

A 28-year-old elite volleyball player complains of vague posterior shoulder pain and isolated weakness with external rotation. Forward elevation and internal rotation strength are completely normal. An MRI demonstrates a paralabral cyst.

Where is the most likely anatomic location of the nerve compression?

Explanation

Isolated external rotation weakness (infraspinatus) without supraspinatus involvement indicates suprascapular nerve compression at the spinoglenoid notch. Compression more proximally at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 92

A 32-year-old man presents with right shoulder weakness 3 months after a severe viral illness. Examination demonstrates pronounced medial winging of the scapula when he pushes against a wall. EMG confirms a localized nerve injury. If nonoperative management fails after 12 to 18 months, which surgical procedure is most appropriate?

Explanation

Medial winging of the scapula is caused by serratus anterior palsy secondary to long thoracic nerve injury. The split pectoralis major tendon transfer is the procedure of choice for symptomatic, irreversible serratus anterior palsy.

Question 93

A 60-year-old man falls on an outstretched arm, experiencing a popping sensation in his shoulder followed by isolated weakness with internal rotation. Which of the following physical examination tests is considered the most sensitive for diagnosing a partial tear involving the upper border of the subscapularis tendon?

Explanation

The bear hug test is highly sensitive for detecting tears of the upper portion of the subscapularis tendon. It places the tendon under maximal tension, often revealing subtle tears that might be missed by the belly-press or lift-off tests.

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

Orthopedic Shoulder 2026 MCQs: Board Review Questions & Answers (Part 4)

Key Takeaway

Orthopedic Shoulder 2026 MCQs: Board Review Questions & Answers (Part 4)

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