2026 Orthopedic Shoulder MCQs: Board Review 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 72-year-old woman undergoes reverse total shoulder arthroplasty. At her 2-year follow-up, radiographs show inferior scapular notching. Which of the following surgical techniques decreases the risk of this complication?

Explanation

Inferior tilt and inferior translation of the glenosphere in RTSA help prevent scapular notching. This avoids mechanical impingement of the humeral component against the scapular neck during adduction.

Question 27

A 24-year-old rugby player has recurrent anterior shoulder instability. CT shows 25% anterior glenoid bone loss and an engaging Hill-Sachs lesion. What is the most appropriate surgical treatment?

Explanation

The Latarjet procedure (coracoid transfer) is indicated for anterior shoulder instability with critical glenoid bone loss (>20-25%). It provides a triple blocking effect to stabilize the joint.

Question 28

A 55-year-old man presents with anterior shoulder pain and weakness following a fall. Physical examination reveals increased passive external rotation compared to the contralateral side, and a positive belly-press test. Which tendon is most likely injured?

Explanation

Increased passive external rotation and a positive belly-press or lift-off test are classic signs of a subscapularis tendon rupture. The subscapularis is the primary internal rotator of the shoulder.

Question 29

A 28-year-old volleyball player complains of vague posterior shoulder pain and weakness. Exam reveals isolated atrophy of the infraspinatus with preserved supraspinatus muscle bulk. Where is the most likely site of nerve compression?

Explanation

Entrapment of the suprascapular nerve at the spinoglenoid notch affects only the infraspinatus, causing isolated weakness and atrophy. Entrapment at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 30

A 22-year-old baseball pitcher has posterior shoulder pain during the late cocking phase of throwing. He has a loss of internal rotation (GIRD) of 25 degrees. MRI shows articular-sided partial-thickness tearing of the posterior supraspinatus. What is the most likely diagnosis?

Explanation

Internal impingement occurs in overhead athletes during late cocking and early acceleration, leading to articular-sided rotator cuff tears and posterosuperior labral fraying. It is strongly associated with Glenohumeral Internal Rotation Deficit (GIRD).

Question 31

A 20-year-old male baseball pitcher sustains a Type II SLAP tear. Nonoperative management fails. What is the most appropriate next step in management to allow return to his previous level of play?

Explanation

In young, active overhead athletes, arthroscopic repair of a Type II SLAP lesion is often attempted to restore native anatomy and function. However, return to previous pitching level remains challenging.

Question 32

A 32-year-old male bodybuilder feels a pop in his anterior axilla while performing a heavy bench press. Examination reveals bruising and a loss of the anterior axillary fold contour. Weakness will be most pronounced in which of the following shoulder motions?

Explanation

The pectoralis major acts primarily to adduct, internally rotate, and flex the humerus. Rupture commonly occurs during eccentric loading, such as the eccentric phase of a bench press.

Question 33

A 40-year-old woman develops lateral scapular winging after a cervical lymph node biopsy. Which nerve was most likely injured?

Explanation

Injury to the spinal accessory nerve paralyzes the trapezius, resulting in lateral scapular winging. Medial winging is caused by long thoracic nerve injury (serratus anterior paralysis).

Question 34

A 65-year-old man who underwent anatomic total shoulder arthroplasty 5 years ago presents with progressively worsening shoulder pain.

The "rocking horse" phenomenon in anatomic total shoulder arthroplasty, which leads to glenoid loosening, is most directly caused by:

Explanation

Superior migration of the humeral head due to rotator cuff insufficiency leads to eccentric superior loading of the glenoid. This creates the "rocking horse" effect and subsequent aseptic loosening.

Question 35

A 50-year-old woman with type 1 diabetes presents with severe, progressive shoulder pain and stiffness over the last 4 months. She has an equal loss of active and passive range of motion, most notably in external rotation. What is the underlying pathophysiology of her condition?

Explanation

Adhesive capsulitis (frozen shoulder) is characterized by fibroblastic proliferation and thickening/contracture of the joint capsule. Diabetes is a major risk factor, and restricted passive external rotation is the hallmark finding.

Question 36

A 78-year-old right-hand dominant woman sustains a displaced 3-part proximal humerus fracture involving the surgical neck and greater tuberosity. She has severe pre-existing glenohumeral osteoarthritis. What is the most appropriate surgical intervention?

Explanation

In an elderly patient with a complex proximal humerus fracture and pre-existing glenohumeral osteoarthritis, reverse total shoulder arthroplasty is indicated. It bypasses the need for tuberosity healing to restore elevation and addresses the arthritic joint.

Question 37

A 28-year-old elite weightlifter complains of superior shoulder pain aggravated by dips and the bench press. Radiographs reveal widening of the acromioclavicular joint and subchondral cystic changes of the distal clavicle. If conservative management fails, what is the treatment of choice?

Explanation

Distal clavicle osteolysis commonly affects weightlifters. When nonoperative treatments fail, arthroscopic distal clavicle excision (Mumford procedure) provides excellent pain relief.

Question 38

A 35-year-old man presents with vague posterior shoulder pain and numbness over the lateral deltoid. An MRI of the shoulder demonstrates isolated atrophy of the teres minor. Which of the following structures is most likely compressed?

Explanation

Quadrilateral space syndrome is caused by compression of the axillary nerve and posterior circumflex humeral artery. It classically leads to isolated teres minor atrophy and lateral shoulder paresthesia.

Question 39

A 42-year-old man suddenly developed excruciating, unprovoked right shoulder pain 2 weeks ago that lasted for several days. As the pain subsided, he noted profound weakness in shoulder abduction and external rotation. EMG shows active denervation of the supraspinatus and deltoid. What is the most likely diagnosis?

Explanation

Parsonage-Turner syndrome (idiopathic brachial neuritis) classically presents with severe, acute-onset shoulder pain. This is followed by patchy muscle weakness and atrophy as the pain begins to improve.

Question 40

A 25-year-old cyclist falls onto his shoulder and sustains a midshaft clavicle fracture.

Which of the following is a widely accepted absolute indication for immediate open reduction and internal fixation?

Explanation

Absolute indications for ORIF of a clavicle fracture include open fractures, impending skin compromise (ischemia/tenting), and vascular injury. Shortening and angulation are relative indications.

Question 41

A 30-year-old male falls directly on his shoulder adducted to his side. Radiographs show a 150% superior displacement of the distal clavicle relative to the acromion. What is the classification and recommended initial management for this injury?

Explanation

A Type V AC joint injury is characterized by 100% to 300% superior displacement of the clavicle due to rupture of both the AC and CC ligaments with deltotrapezial fascial stripping. Operative reconstruction is generally recommended.

Question 42

A 35-year-old woman underwent a cervical lymph node biopsy in the posterior triangle of her neck 6 weeks ago. She now complains of a drooping right shoulder, dull aching pain, and an inability to actively elevate her arm above the horizontal plane. Physical examination reveals lateral winging of the scapula. Which of the following nerves was most likely injured?

Explanation

Injury to the spinal accessory nerve (CN XI) in the posterior triangle leads to trapezius paralysis. This presents with a drooping shoulder, weakness in overhead elevation, and lateral scapular winging.

Question 43

A 40-year-old man presents with a locked posterior shoulder dislocation following a seizure. Advanced imaging demonstrates an anteromedial humeral head defect (reverse Hill-Sachs lesion) involving 40% of the articular surface. The glenoid is intact. What is the most appropriate surgical management?

Explanation

For reverse Hill-Sachs defects between 25% and 45% of the articular surface in a young, active patient, structural bone grafting or osteochondral allograft reconstruction is the treatment of choice to restore joint stability.

Question 44

A 22-year-old elite baseball pitcher presents with vague posterior shoulder pain. Physical examination of the throwing shoulder reveals 130 degrees of external rotation (ER) and 30 degrees of internal rotation (IR) at 90 degrees of abduction. The contralateral shoulder has 100 degrees of ER and 60 degrees of IR. The total arc of motion is 160 degrees bilaterally. What is the most appropriate initial management?

Explanation

This patient has glenohumeral internal rotation deficit (GIRD) with a preserved total arc of motion. The initial treatment is non-operative, focusing on sleeper stretches to address posterior capsular tightness.

Question 45

Which of the following radiographic findings in a proximal humerus fracture is considered the strongest predictor of subsequent humeral head ischemia and avascular necrosis?

Explanation

According to the Hertel criteria, a short metaphyseal head extension (<8 mm) and a disrupted medial hinge are highly predictive of ischemia, as they suggest disruption of the arcuate branch of the anterior humeral circumflex artery.

Question 46

A 30-year-old male volleyball player presents with painless weakness in external rotation of his dominant shoulder. Abduction strength is normal. An MRI confirms a paralabral cyst in the spinoglenoid notch. Which of the following associated pathologies is most likely the root cause of this cyst?

Explanation

A paralabral cyst in the spinoglenoid notch selectively compresses the suprascapular nerve branch to the infraspinatus, causing isolated external rotation weakness. It is highly associated with posterior labral tears acting as a one-way valve.

Question 47

A 25-year-old male presents with pronounced medial winging of his right scapula after sustaining a direct blow to the lateral chest wall during a hockey game. He is unable to perform a wall push-up without the scapula lifting off the thorax. Which muscle and corresponding nerve are primarily affected?

Explanation

Medial winging of the scapula is characteristic of serratus anterior dysfunction, which is caused by an injury to the long thoracic nerve.

Question 48

During the evaluation of a patient with a suspected rotator cuff tear, which of the following isolated physical examination findings is most specific for a complete tear of the subscapularis tendon?

Explanation

The subscapularis is a primary dynamic internal rotator and a crucial secondary static restraint to external rotation. A complete tear often manifests as notably increased passive external rotation compared to the uninjured side.

Question 49

Scapular notching is a recognized complication following reverse total shoulder arthroplasty (RTSA). Which of the following glenosphere placements is most strongly associated with an increased incidence of this complication?

Explanation

Scapular notching occurs due to mechanical impingement of the humeral cup on the inferior scapular neck. Superior tilt and medialization of the glenosphere increase the likelihood of this impingement.

Question 50

A 32-year-old bodybuilder feels a sudden, painful 'pop' in his anterior chest while performing a heavy bench press. Examination reveals an asymmetric anterior axillary fold and significant ecchymosis over the medial arm. Which of the following describes the most common anatomical site of this rupture?

Explanation

Pectoralis major ruptures most commonly occur as an avulsion of the sternocostal head from its insertion on the proximal humerus, typically occurring during eccentric loading such as the downward phase of a bench press.

Question 51

A 24-year-old rugby player undergoes an open Latarjet procedure for recurrent anterior shoulder instability associated with 25% glenoid bone loss. Postoperatively, he exhibits profound weakness in elbow flexion and decreased sensation over the lateral aspect of the forearm. Which nerve was most likely injured during the coracoid transfer?

Explanation

The musculocutaneous nerve enters the coracobrachialis 5-8 cm distal to the coracoid process. It is at significant risk of traction or direct transection during the Latarjet procedure, leading to biceps/brachialis weakness and lateral forearm numbness.

Question 52

The rotator interval is a critical anatomic space in the shoulder that is often targeted in capsular release or plication. Which of the following structures are contained within this interval?

Explanation

The rotator interval is bordered by the subscapularis and supraspinatus tendons. Its contents include the coracohumeral ligament (CHL), the superior glenohumeral ligament (SGHL), and the long head of the biceps tendon.

Question 53

A 68-year-old woman presents with persistent pseudoparalysis and severe shoulder pain after a massive irreparable rotator cuff tear. Clinical examination shows an intact deltoid and teres minor, but she has failed conservative treatment.

What is the most appropriate surgical treatment?

Explanation

Reverse total shoulder arthroplasty is indicated for older patients with massive, irreparable rotator cuff tears and pseudoparalysis, provided the deltoid is functional. It restores tension to the deltoid, allowing for active elevation.

Question 54

A 28-year-old male weightlifter presents with acute right shoulder pain after a heavy bench press. Examination reveals ecchymosis over the anterior axillary fold and a palpable defect. Loss of contour is most apparent when the patient presses his hands together.

Which of the following is true regarding this injury?

Explanation

Pectoralis major ruptures usually occur at the musculotendinous junction or tendinous insertion of the sternocostal head during eccentric contraction. The pectoralis major inserts onto the lateral lip of the bicipital groove.

Question 55

A 24-year-old baseball pitcher presents with posterior shoulder pain during the late cocking phase of throwing. He has a 20-degree loss of internal rotation compared to the contralateral side. MRI shows articular-sided partial tearing of the posterior supraspinatus and posterosuperior labral fraying.

What is the primary underlying pathophysiology?

Explanation

The clinical presentation is classic for internal impingement associated with Glenohumeral Internal Rotation Deficit (GIRD). The primary driver is a contracture of the posteroinferior capsule, leading to posterosuperior shift of the humeral head in maximum abduction.

Question 56

A 35-year-old male presents with recurrent anterior shoulder instability. A CT scan with 3D reconstruction demonstrates 25% anterior glenoid bone loss.

Which of the following procedures is most appropriate?

Explanation

In patients with recurrent anterior shoulder instability and critical anterior glenoid bone loss (>20-25%), an arthroscopic Bankart repair has a high failure rate. The Latarjet procedure (coracoid transfer) is the standard treatment to reconstruct the bony defect.

Question 57

A 42-year-old construction worker sustained an electrical shock and was diagnosed with a locked posterior shoulder dislocation. CT scan shows an anteromedial humeral head impaction fracture (reverse Hill-Sachs lesion) involving 30% of the articular surface.

The duration of dislocation is 2 weeks. What is the recommended treatment?

Explanation

For a reverse Hill-Sachs defect between 20% and 40% of the articular surface, a modified McLaughlin procedure is indicated. This involves transferring the lesser tuberosity or subscapularis into the defect to prevent engagement on the posterior glenoid rim.

Question 58

A 55-year-old male complains of poorly localized right shoulder pain and weakness, predominantly when externally rotating his arm. Examination reveals isolated atrophy of the infraspinatus with weakness in external rotation. Supraspinatus strength is normal.

MRI is most likely to show:

Explanation

Isolated infraspinatus atrophy and weakness is highly suggestive of suprascapular nerve entrapment at the spinoglenoid notch. Entrapment at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 59

A 72-year-old man undergoes a reverse total shoulder arthroplasty. At 2-year follow-up, radiographs show grade 2 scapular notching. Which of the following surgical techniques minimizes this complication?

Explanation

Scapular notching in reverse TSA is caused by mechanical impingement of the humeral component against the inferior scapular neck. Inferior placement with an inferior tilt of the glenosphere, as well as lateralization, reduces this risk.

Question 60

A 28-year-old volleyball player presents with insidious onset of posterior shoulder pain and weakness. Examination reveals isolated atrophy of the infraspinatus with normal supraspinatus strength. An MRI shows a paralabral cyst. Where is the cyst most likely located?

Explanation

A paralabral cyst at the spinoglenoid notch compresses the suprascapular nerve after it has innervated the supraspinatus. This leads to isolated infraspinatus weakness and atrophy.

Question 61

A 22-year-old rugby player has recurrent anterior shoulder instability. A CT scan with 3D reconstruction demonstrates 28% glenoid bone loss. What is the most appropriate definitive management?

Explanation

For recurrent anterior shoulder instability with critical glenoid bone loss (>20-25%), an arthroscopic Bankart repair has an unacceptably high failure rate. A coracoid transfer addresses the bony defect and provides a dynamic sling effect.

Question 62

A 78-year-old woman sustains a highly comminuted 4-part proximal humerus fracture. Her history is significant for severe rotator cuff arthropathy and pseudoparalysis of the shoulder prior to the injury. A representative radiograph is similar to

What is the most appropriate surgical treatment?

Explanation

Reverse total shoulder arthroplasty is the treatment of choice for a 4-part proximal humerus fracture in an elderly patient with pre-existing rotator cuff arthropathy. It provides reliable pain relief and functional restoration without relying on tuberosity healing.

Question 63

A 24-year-old professional baseball pitcher presents with posterior shoulder pain during the late cocking phase of throwing. Examination shows 15 degrees of internal rotation and 130 degrees of external rotation. What is the most likely pathophysiologic mechanism of his shoulder pain?

Explanation

Glenohumeral internal rotation deficit (GIRD) in overhead throwers leads to a biomechanical shift. This causes internal impingement, where the undersurface of the rotator cuff impinges against the posterosuperior glenoid, frequently creating a peel-back SLAP lesion.

Question 64

A 19-year-old football player sustains a direct blow to the anteromedial chest. He complains of severe pain at the sternoclavicular joint, dysphagia, and a choking sensation. What is the most critical next step in management?

Explanation

Posterior sternoclavicular dislocations can fatally compress mediastinal structures like the trachea, esophagus, and great vessels. Management requires a CT scan for diagnosis and urgent closed reduction in the operating room with thoracic surgery available.

Question 65

A 55-year-old man presents with anterior shoulder pain and weakness after a fall onto an outstretched hand. On examination, he has increased passive external rotation. Which of the following physical examination tests would most likely be positive?

Explanation

Increased passive external rotation following acute trauma is highly suggestive of a subscapularis tear. The bear hug test, belly-press test, and lift-off test specifically evaluate the integrity of the subscapularis muscle.

Question 66

A 30-year-old competitive weightlifter feels a sudden pop in his anterior axillary fold while performing a heavy bench press. Examination reveals bruising and a loss of the anterior axillary contour. Surgical repair is planned. Where is the anatomical footprint of the torn structure?

Explanation

The pectoralis major muscle inserts onto the lateral lip of the bicipital groove. Ruptures most commonly occur at the sternocostal head insertion during eccentric loading and are best treated with early surgical repair in active patients.

Question 67

A 45-year-old woman develops acute, severe right shoulder pain that wakes her from sleep. The pain lasts for two weeks and then subsides, but she subsequently develops profound weakness in shoulder elevation and external rotation. MRI of the shoulder is unremarkable. What is the most likely diagnosis?

Explanation

Parsonage-Turner syndrome (brachial neuritis) features an acute onset of severe shoulder pain that resolves, followed by patchy lower motor neuron weakness. Diagnosis is typically confirmed with electromyography (EMG).

Question 68

A 20-year-old collegiate gymnast complains of deep shoulder pain and mechanical catching. MR arthrogram demonstrates a detachment of the superior labrum and biceps anchor from the glenoid. Which of the following is the most appropriate surgical intervention?

Explanation

In a young, high-demand athlete, a Type II SLAP tear (detachment of the superior labrum and biceps anchor) is optimally treated with arthroscopic repair. Older patients generally have better outcomes with biceps tenodesis to prevent stiffness and failure.

Question 69

A 62-year-old man presents with insidious onset of mild shoulder pain and stiffness 14 months after an anatomic total shoulder arthroplasty. Inflammatory markers are normal, but joint aspiration yields a positive culture after 10 days. What is the most likely causative organism?

Explanation

Cutibacterium acnes (formerly Propionibacterium acnes) is an indolent, slow-growing anaerobic organism commonly responsible for late periprosthetic shoulder infections. Cultures must be held for at least 14 days to avoid false-negative results.

Question 70

A 25-year-old man sustains an anterior shoulder dislocation during a seizure. Following closed reduction, he is noted to have numbness over the lateral aspect of the shoulder. Which muscle's function is most likely impaired?

Explanation

The axillary nerve is the most commonly injured nerve during an anterior shoulder dislocation. It provides sensation to the lateral shoulder (regimental badge area) and motor innervation to the deltoid and teres minor.

Question 71

A 35-year-old mountain biker falls directly onto the point of his shoulder. Radiographs show a 100% superior displacement of the clavicle relative to the acromion, with an increased coracoclavicular distance. What ligaments are ruptured?

Explanation

A Type III acromioclavicular (AC) joint injury involves complete rupture of both the acromioclavicular and coracoclavicular (conoid and trapezoid) ligaments. This results in superior translation of the clavicle by 25% to 100%.

Question 72

A 48-year-old woman presents with agonizing shoulder pain of sudden onset without trauma. Radiographs reveal a homogenous, well-defined radiopacity superior to the greater tuberosity as shown in

Which phase of the disease process is typically the most painful?

Explanation

Calcific tendinitis progresses through precalcific, calcific (formative, resting, resorptive), and postcalcific phases. The resorptive phase is characterized by intense vascular ingrowth and macrophage infiltration, causing extreme pain.

Question 73

A 65-year-old manual laborer undergoes arthroscopy for a partial, fraying tear of the long head of the biceps tendon involving 60% of its substance. He expresses a strong desire to avoid cosmetic deformity and cramping. What is the most appropriate management?

Explanation

Significant partial tears (>50%) of the long head of the biceps tendon are treated with tenotomy or tenodesis. Tenodesis is preferred in active patients or those specifically wishing to avoid the "Popeye" deformity and cramping associated with a tenotomy.

Question 74

A 72-year-old man undergoes a reverse total shoulder arthroplasty (RTSA) for cuff tear arthropathy. At his 2-year follow-up, radiographs demonstrate inferior scapular notching that extends beyond the inferior screw of the baseplate. According to the Sirveaux classification, what grade of notching is present?

Explanation

According to Sirveaux, Grade 1 is notching confined to the pillar. Grade 2 reaches the inferior screw, Grade 3 extends beyond the inferior screw, and Grade 4 extends under the baseplate.

Question 75

A 35-year-old man presents with a locked posterior shoulder dislocation after a seizure. CT reveals an anteromedial humeral head defect (reverse Hill-Sachs lesion) involving 35% of the articular surface. The patient is active and desires to return to manual labor. What is the most appropriate surgical management?

Explanation

For reverse Hill-Sachs defects between 25% and 40%, structural bone grafting (osteochondral allograft) is typically recommended to restore articular congruity. Lesser tuberosity transfer (modified McLaughlin) is preferred for defects between 10% and 25%.

Question 76

A 28-year-old professional rugby player sustains an acute type V acromioclavicular (AC) joint separation. He is scheduled for an anatomic coracoclavicular (CC) ligament reconstruction. To accurately recreate the native anatomy, the surgeon must place the grafts based on the anatomic insertions. Which of the following statements regarding the CC ligaments is true?

Explanation

The conoid ligament is located medial and posterior to the trapezoid ligament and inserts on the conoid tubercle. The conoid is the primary restraint to superior translation, while the trapezoid primarily resists horizontal/axial compression.

Question 77

A 45-year-old cyclist falls directly onto his right shoulder and sustains a midshaft clavicle fracture. Which of the following radiographic parameters is the strongest biomechanical and clinical indication for open reduction and internal fixation?

Explanation

Shortening of greater than 2 cm in midshaft clavicle fractures is highly associated with symptomatic nonunion and persistent shoulder dysfunction, making it a strong indication for operative intervention.

Question 78

A 22-year-old collegiate baseball pitcher presents with vague, deep shoulder pain and decreased throwing velocity. MRI arthrogram reveals a Type II SLAP tear. During arthroscopy, what biomechanical mechanism is most commonly observed to exacerbate the pathology when the arm is placed in the late cocking phase of throwing?

Explanation

The peel-back mechanism occurs when the arm is placed in abduction and maximal external rotation (late cocking phase). This position causes the biceps vector to shift posteriorly, creating a torsional force that peels the superior labrum off the glenoid.

Question 79

A 74-year-old woman presents with long-standing shoulder pain and inability to elevate her arm past 40 degrees. She has a positive drop arm sign and hornblower's sign. Radiographs demonstrate severe superior migration of the humeral head with articulation against the acromion.

Which of the following is the most reliable surgical option to restore active forward elevation?

Explanation

In an elderly patient with rotator cuff tear arthropathy and pseudoparalysis, a reverse total shoulder arthroplasty (RTSA) provides the most reliable restoration of active forward elevation by utilizing the deltoid muscle.

Question 80

A 32-year-old competitive weightlifter feels a pop in his anterior axilla while performing a heavy bench press. Examination reveals loss of the anterior axillary fold and weakness in internal rotation. Operative exploration is planned. Where should the surgeon expect to find the native insertion of the ruptured tendon?

Explanation

The pectoralis major tendon inserts onto the lateral lip of the bicipital groove. Ruptures typically occur at or near this tendinous insertion during eccentric loading, such as the descent phase of a bench press.

Question 81

A 29-year-old elite volleyball player complains of vague posterior shoulder pain and progressive weakness. Physical examination reveals isolated weakness in external rotation with the arm at the side. Forward elevation and internal rotation strength are normal. MRI demonstrates a paralabral cyst. Where is the cyst most likely located?

Explanation

A cyst at the spinoglenoid notch compresses the suprascapular nerve after it has already innervated the supraspinatus, leading to isolated infraspinatus denervation and weakness in external rotation.

Question 82

A 55-year-old woman with type 1 diabetes presents with severe left shoulder pain that is worse at night and progressive stiffness over the past 3 months. Physical exam reveals passive external rotation limited to 10 degrees. Radiographs are normal. What is the initial treatment of choice?

Explanation

The patient has adhesive capsulitis (freezing phase). Initial treatment is nonoperative, focusing on gentle, sustained physical therapy stretching and intra-articular corticosteroid injections to decrease pain and inflammation.

Question 83

A 21-year-old man undergoes a Latarjet procedure for recurrent anterior shoulder instability with 30% glenoid bone loss. The stabilizing "sling effect" provided by this procedure is primarily dependent on the dynamic tension of which structure?

Explanation

The Latarjet procedure provides stability through a "sling effect" created by the conjoined tendon (short head of the biceps and coracobrachialis) pressing against the lower subscapularis and anterior capsule when the arm is abducted and externally rotated.

Question 84

Recent anatomic injection studies and quantitative MRI analyses have challenged traditional teaching regarding the vascular supply of the proximal humerus. According to current literature, which vessel provides the predominant blood supply to the articular segment of the humeral head?

Explanation

Recent studies demonstrate that the posterior humeral circumflex artery provides the dominant blood supply to the humeral head, supplying up to 64% of the articular segment, refuting the traditional belief that the anterior humeral circumflex was primary.

Question 85

A 68-year-old woman presents 3 months after an anatomic total shoulder arthroplasty (TSA) complaining of weakness and a new onset of pain.

Examination reveals passive external rotation of 80 degrees on the operative side compared to 40 degrees on the contralateral side. She has a positive belly-press test. What is the most likely diagnosis?

Explanation

Excessive passive external rotation combined with a positive belly-press test after an anatomic TSA strongly suggests subscapularis failure. This is a known complication following the tenotomy or peel performed during the surgical approach.

Question 86

A 34-year-old recreational weightlifter complains of vague, poorly localized posterior shoulder pain and numbness over the lateral deltoid. MRI demonstrates isolated atrophy of the teres minor. The affected nerve is compressed in a space bordered by which of the following structures?

Explanation

The patient has quadrilateral space syndrome, compressing the axillary nerve. The quadrilateral space is bordered superiorly by the teres minor, inferiorly by the teres major, medially by the long head of the triceps, and laterally by the surgical neck of the humerus.

Question 87

A 19-year-old football player sustains a high-energy blow to the medial clavicle. In the emergency department, he complains of shoulder pain, shortness of breath, and difficulty swallowing. Physical exam reveals a palpable depression at the medial end of the clavicle. What is the most appropriate next step in management?

Explanation

This is a posterior sternoclavicular dislocation, a true orthopedic emergency due to potential compression of the trachea, esophagus, and great vessels. A CT scan is required, and reduction should be performed in the OR with cardiothoracic surgery backup.

Question 88

A 26-year-old male presents with winging of his right scapula following a protracted illness.

On physical examination, the medial border of the scapula is prominent, especially when he pushes against a wall. Which nerve is most likely affected?

Explanation

Medial scapular winging is caused by serratus anterior paralysis, which is innervated by the long thoracic nerve. Lateral winging is typically due to trapezius dysfunction (spinal accessory nerve).

Question 89

A 20-year-old elite collegiate tennis player presents with shoulder pain during the serve. Physical examination reveals glenohumeral internal rotation deficit (GIRD) of 25 degrees compared to the contralateral side, and 15 degrees of increased external rotation. The underlying pathophysiology of GIRD is most directly related to contracture of which structure?

Explanation

GIRD in overhead athletes is primarily caused by contracture and thickening of the posterior capsule and the posterior band of the inferior glenohumeral ligament (IGHL) resulting from repetitive microtrauma during the deceleration phase of throwing.

Question 90

A 70-year-old woman is 6 months status post a reverse total shoulder arthroplasty (RTSA) for massive rotator cuff tear. She was doing well until she experienced a sudden onset of superior shoulder pain without any distinct trauma.

Radiographs indicate an acromial stress fracture. Which biomechanical alteration inherent to RTSA most directly contributes to this complication?

Explanation

RTSA medializes and distalizes the center of rotation, which significantly increases the tension and lever arm of the deltoid. This increased load can lead to acromial or scapular spine stress fractures.

Question 91

A 13-year-old male baseball pitcher complains of right shoulder pain during the acceleration phase of throwing. He has tenderness over the proximal humerus. Radiographs show widening of the proximal humeral physis compared to the contralateral side. What is the most appropriate initial treatment?

Explanation

Little League shoulder is a stress fracture (epiphysiolysis) of the proximal humeral physis. Treatment consists of complete cessation of throwing (rest) for 6 to 12 weeks, followed by a gradual return-to-throwing program.

Question 92

A 42-year-old man presents with a 3-week history of severe, unrelenting shoulder pain that woke him from sleep. The pain has now begun to subside, but he has noticed profound weakness in overhead elevation and external rotation. MRI of the shoulder reveals no rotator cuff tear. EMG confirms acute denervation of the supraspinatus, infraspinatus, and deltoid. What is the most likely diagnosis?

Explanation

Parsonage-Turner syndrome (idiopathic brachial neuritis) classically presents with acute, severe shoulder pain followed by patchy weakness and atrophy of shoulder girdle muscles as the pain subsides.

Question 93

During pre-operative planning for a recurrent anterior shoulder instability patient, a 3D CT scan is obtained. The surgeon uses the 'best-fit circle' method on the sagittal en face view to calculate glenoid bone loss. At what threshold of anterior glenoid bone loss is an arthroscopic Bankart repair generally considered to have an unacceptably high failure rate, making a bone block procedure (e.g., Latarjet) the standard recommendation?

Explanation

Critical glenoid bone loss is historically defined as >20-25%. At this threshold, soft-tissue procedures like Bankart repair have unacceptably high failure rates, and bony augmentation (e.g., Latarjet) is indicated.

Question 94

A 72-year-old woman presents with lateral shoulder pain 2 years after undergoing a reverse total shoulder arthroplasty (RTSA). Radiographs reveal grade 3 scapular notching. Which of the following surgical technique modifications during the index procedure would have best minimized this complication?

Explanation

Scapular notching in RTSA is best minimized by placing the glenosphere inferiorly with a slight inferior overhang and a neutral or inferior tilt. This biomechanical adjustment prevents impingement of the medial humeral component on the inferior scapular neck during arm adduction.

Question 95

A 24-year-old professional rugby player has a history of recurrent anterior shoulder instability. A 3D CT scan demonstrates 28% anterior glenoid bone loss. He is planned for a Latarjet procedure. Which of the following describes the primary stabilizing mechanism of this procedure when the arm is in the abduction-external rotation (ABER) position?

Explanation

The Latarjet procedure provides stability via a 'triple effect'. Biomechanical studies demonstrate that in the vulnerable ABER position, the conjoint tendon acting as a dynamic sling across the inferior subscapularis and capsule provides the primary stabilizing force.

Question 96

A 28-year-old professional volleyball player presents with insidious onset of vague posterior right shoulder pain and weakness. Physical examination demonstrates isolated weakness in external rotation with the arm at the side, but forward elevation and abduction strength are completely normal. An MRI is most likely to show a paralabral cyst in which of the following anatomic locations?

Explanation

Isolated external rotation weakness (infraspinatus) with normal abduction (supraspinatus) indicates suprascapular nerve entrapment distal to the supraspinatus innervation, specifically at the spinoglenoid notch. Entrapment at the more proximal suprascapular notch would affect both muscles.

Question 97

A 68-year-old woman sustains a displaced proximal humerus fracture after a ground-level fall.

According to Hertel's criteria, which of the following specific radiographic findings is the most reliable predictor of ensuing avascular necrosis of the humeral head?

Explanation

Hertel established that a short calcar segment (metaphyseal head extension less than 8 mm) and a disrupted medial hinge (greater than 2 mm) are highly predictive of humeral head ischemia. These findings correlate strongly with disruption of the arcuate artery blood supply.

Question 98

A 32-year-old weightlifter felt a sudden tearing sensation in his anterior axilla while performing a heavy bench press. Examination reveals loss of the anterior axillary fold and weakness in internal rotation. Surgical exploration is planned for a complete tear of the sternal head of the pectoralis major. Where does the sternal head normally insert on the humerus relative to the clavicular head?

Explanation

The pectoralis major tendon twists 180 degrees before inserting on the lateral lip of the bicipital groove. Due to this twist, the inferiorly originating sternal head inserts proximal and deep to the superiorly originating clavicular head.

Question 99

An 18-year-old male presents to the emergency department after a high-speed motor vehicle collision. He complains of left medial clavicle pain, dysphagia, and mild dyspnea. Examination reveals a palpable void at the left sternoclavicular joint. After plain radiographs, what is the most appropriate next step in management?

Explanation

Posterior sternoclavicular dislocations can cause life-threatening compression of mediastinal structures, including the trachea, esophagus, and great vessels. A CT angiogram is essential to evaluate for retrosternal injury, and thoracic surgery backup is required during reduction due to the high risk of catastrophic hemorrhage.

Question 100

A 55-year-old woman with type 1 diabetes mellitus presents with progressive, severe shoulder stiffness and pain over the past 6 months. Examination demonstrates equal restriction of both active and passive range of motion.

What is the classic histologic finding in the joint capsule of patients with this condition?

Explanation

Adhesive capsulitis (frozen shoulder) is a fibroproliferative condition rather than an acute inflammatory one. Histologic analysis of the capsule classically demonstrates a dense matrix of type III collagen populated by a high number of fibroblasts and myofibroblasts without significant acute inflammatory cells.

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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