Shoulder Orthopedics MCQs Set 3: ABOS Board Prep

Question 1

Flexion and extension of the elbow occur about an axis of rotation that

Shoulder 2000 Practice Questions: Set 3 (Solved) - Figure 1

Explanation

The elbow mimics a true hinge and flexes and extends around an axis that is centered in the centers of the trochlea and capitellum. The medial epicondyle is not perfectly isometrically placed; rather the axis of rotation passes through a point on the anteroinferior aspect of the medial epicondyle. Application of a hinged external fixator is possible because of the fact that there is a single axis of rotation. Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, PA, WB Saunders, 1993, pp 53-54. London JT: Kinematics of the elbow. J Bone Joint Surg Am 1981;63:529-535.

Question 2

Figure 27 shows the radiograph of a 26-year-old man who sustained a closed head injury and a closed elbow dislocation 6 weeks ago. Examination reveals 65 degrees to 115 degrees of flexion, and intensive physical therapy has resulted in no improvement. A decision regarding the timing of surgical correction of the contracture should be based on

Shoulder 2000 Practice Questions: Set 3 (Solved) - Figure 2

Explanation

The patient has heterotopic ossification, a more common finding in patients who have sustained head injuries. Treatment will require removal of the heterotopic bone and anterior and posterior capsulectomies. The main concern about timing is the possible recurrence of heterotopic bone. While an extended wait was once thought necessary, this is no longer true. The timing is based on the time since injury and evidence of bone maturation on plain radiographs. A sharp marginal demarcation of the new bone and a trabecular pattern within it are usually present 3 to 6 months after onset, indicating that it is safe to proceed with surgical excision. It is not necessary to wait more than 6 months. Bone scan results are not good indicators because they may remain "hot" for long periods of time. The levels of alkaline phosphatase and serum calcium-phosphorus product do not need to be measured.

Question 3

A 70-year-old man who underwent an uncomplicated large rotator cuff repair 6 months ago is now seeking a second opinion regarding persistent pain and weakness in his shoulder. Examination reveals that his incision is well healed and unreactive. The surgical report suggests that the tendons were secured back to bone with sutures through the greater tuberosity. Figure 28 shows a radiograph that was obtained 1 week ago. What is the most likely diagnosis?

Shoulder 2000 Practice Questions: Set 3 (Solved) - Figure 3

Explanation

Symptoms can persist following a rotator cuff repair for a variety of reasons. In the early postoperative period, infection is the primary concern. Stiffness and loss of motion can occur because of postoperative scarring. Complex regional pain syndrome can occur but is rare, and the diagnosis is not made with a plain radiograph. This radiograph shows a superiorly migrated humeral head that articulates with the acromion, indicating that the repair has failed. While large to massive tears may fail more commonly than once thought, the clinical outcome may be satisfactory in many patients. Mansat P, Cofield RH, Kersten TE, Rowland CM: Complications of rotator cuff repair. Orthop Clin North Am 1997;28:205-213.

Question 4

A 29-year-old man who lifts weights states that he injured his left shoulder while performing a bench press 2 days ago. The following morning he noted ecchymosis and swelling in the left chest wall. Examination reveals ecchymosis and tenderness and deformity in the left anterior chest wall and axillary fold that is accentuated with resisted adduction of the arm. Passive range of motion beyond 90 degrees of forward flexion and 45 degrees of external rotation is extremely painful. Glenohumeral stability is difficult to assess because of severe guarding. Figure 29 shows an MRI scan. Management should consist of

Shoulder 2000 Practice Questions: Set 3 (Solved) - Figure 4

Explanation

Rupture of the pectoralis major tendon most commonly occurs during bench pressing. Wolfe and associates have shown that the most inferiorly located fibers of the sternal head lengthen disproportionately during the final 30 degrees of humeral extension during the bench press. This creates a mechanical disadvantage in the final portion of the eccentric phase of the lift; with forceful flexion of the shoulder these maximally stretched fibers may rupture. In most patients, particularly in young athletes, the treatment of choice is anatomic repair of the ruptured tendon to its insertion in the proximal humerus either with suture anchors or transosseous sutures. Following surgery, most patients experience a near normal return of strength and significant improvement in the cosmetic appearance of the deformity. While more technically challenging, repair of chronic rupture is possible and is indicated in some patients. Wolfe SW, Wickiewicz TL, Cavanaugh JT: Ruptures of the pectoralis major muscle: An anatomic and clinical analysis. Am J Sports Med 1992;20:587-593.

Question 5

What range of motion parameters are required for a patient with posttraumatic elbow stiffness to accomplish all the normal activities of daily living?

Explanation

Activities of daily living such as dressing, eating, and bathing can all be performed with elbow motion through a 100 degrees arc of flexion and extension (30 degrees to 130 degrees) and a 100 degrees arc of forearm rotation (50 degrees pronation, 50 degrees supination). Some patients can accomplish these activities of daily living with 10 degrees less motion at each end point. This is referred to as the functional arc of motion. Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 283-294.

Question 6

A 24-year-old athlete has a painful right shoulder. Figure 30 shows an intra-articular photograph that was obtained through a posterior portal during arthroscopy; the labrum is indicated by the arrow. Based on these findings, management should consist of

Shoulder 2000 Practice Questions: Set 3 (Solved) - Figure 5

Explanation

The photograph shows a normal variant that is a sublabral hole beneath the anterosuperior labrum. In some instances, the labrum will become confluent with the middle glenohumeral ligament as a stout band. Because this variant is not abnormal, no treatment is necessary. Securing this portion of the labrum to the capsule may tighten the middle glenohumeral ligament complex and restrict external rotation of the arm. Andrews JR, Guerra JJ, Fox GM: Normal and pathologic arthroscopic anatomy of the shoulder, in Andrews JR, Timmerman LA (eds): Diagnostic and Operative Arthroscopy, ed 1. Philadelphia, PA, WB Saunders, 1997, pp 60-76.

Question 7

The use of a screw between the clavicle and the coracoid process to maintain the clavicle and acromioclavicular (AC) joint in a reduced position is a treatment option for AC joint separations. Screw removal is generally recommended after soft-tissue healing. What effect does this rigid coracoclavicular fixation have on shoulder kinematics?

Explanation

This issue has been debated since Inman published his classic study on clavicular rotation in 1944. Subsequently, it has been shown by several authors that the clinical evaluation of patients with either coracoclavicular screws in place or with arthrodesis of the coracoclavicular reveals little to no loss of shoulder motion. This is most likely the result of synchronous motion of the scapula and clavicle in shoulder movements. Flatow EL: The biomechanics of the acromioclavicular, sternoclavicular, and scapulothoracic joints. Instr Course Lect 1993;42:237-245. Kenedy JC, Cameron H: Complete dislocation of the acromioclavicular joint. J Bone Joint Surg Br 1954;36:202-208. Rockwood CA Jr, Williams GR, Young CD: Disorders of the acromioclavicular joint, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1998, vol 1, pp 483-553.

Question 8

Figure 31 shows the AP and lateral radiographs of the elbow of a 56-year-old man with chronic polyarticular rheumatoid arthritis. His function continues to be limited by pain with activities of daily living. Examination shows that his total arc of motion is 110 degrees. Nonsurgical management has failed to provide relief. Treatment should now consist of

Shoulder 2000 Practice Questions: Set 3 (Solved) - Figure 6

Explanation

A semiconstrained prosthesis can provide excellent results in carefully selected patients. Because the radiographs show extensive joint destruction with loss of the capitellum and trochlea, a capitellocondylar total elbow (unconstrained) prosthesis is contraindicated. Elbow fusion is poorly accepted, and the radiographs show too much articular destruction for a radial head excision, synovectomy, or interposition arthroplasty to be effective. Ewald FC, Simmons ED Jr, Sullivan JA, et al: Capitellocondylar total elbow replacement in rheumatoid arthritis: Long-term results. J Bone Joint Surg Am 1993;75:498-507.

Question 9

A 12-year-old pitcher has had a 2-month history of pain in his right dominant shoulder after throwing. He reports that the pain has gradually progressed to the point where he cannot throw without pain. He also notes that the pain now awakens him at night if he has been active. Anti-inflammatory drugs have failed to provide relief. Examination reveals no abnormalities except for some localized tenderness over the proximal humerus. Figures 32a and 32b show radiographs of both shoulders. What is the most likely diagnosis?

Explanation

The history, examination, and radiographs are pathognomonic for Little League shoulder, a stress syndrome of the proximal humeral physis caused by overuse. Complete fracture rarely occurs, and recovery usually occurs with rest. Night pain is always a serious concern and further work-up is needed if the patient does not respond to activity modification. Occult instability is not a real concern in this patient, although it should be included in the differential diagnosis. Albert MJ, Drvaric DM: Little League shoulder: Case report. Orthopedics 1990;13:779-781.

Question 10

Which of the following ligaments is the primary static restraint against inferior translation of the arm when the shoulder is in 0 degrees of abduction?

Explanation

The superior glenohumeral ligament (SGHL) and coracohumeral ligament serve as primary static restraints against inferior translation of the arm when the shoulder is in 0 degrees of abduction. Of these, the coracohumeral ligament has been shown to have a greater cross-sectional area, greater stiffness, and greater ultimate load than the SGHL. The inferior glenohumeral ligament plays a greater stabilizing role with increasing abduction of the arm. The coracoacromial ligament may help provide superior stability, especially when the rotator cuff is deficient. The coracoclavicular ligaments stabilize the acromioclavicular joint. Boardman ND, Debski RE, Warner JJ, et al: Tensile properties of the superior glenohumeral and coracohumeral ligaments. J Shoulder Elbow Surg 1996;5:249-254.

Question 11

A 16-year-old high school student undergoes a routine preparticipation physical examination at the beginning of the school year. Examination reveals marked laxity of both shoulders but only mild generalized laxity in other joints. The load and shift test allows for anterior humeral translation to the glenoid rim and posterior humeral translation beyond the glenoid rim. The sulcus sign is present. What is the next most appropriate step in management?

Explanation

This patient has shoulder laxity without apprehension. Because there is a wide range of normal laxity in asymptomatic shoulders, the physician should inform the student of these findings, recommend shoulder strengthening exercises, and allow unrestricted sports participation unless symptoms develop. Harryman DT, Sidles JA, Harris SL, Matsen FA III: Laxity of the normal glenohumeral joint: A quantitative in vivo assessment. J Shoulder Elbow Surg 1992;1:66-76. Hawkins RJ, Bokor RJ: Clinical evaluation of shoulder problems, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1998, vol 1, p 186. McFarland EG, Campbell G, McDowell J: Posterior shoulder laxity in asymptomatic athletes. Am J Sports Med 1996;24:468-471.

Question 12

A 21-year-old professional baseball player has had painful catching and stiffness in his dominant right elbow for the past year. Examination reveals a flexion contracture of 2 degrees and mild pain with full elbow flexion. Radiographs are shown in Figures 33a and 33b. The most effective management should consist of

Explanation

The radiographs show osteochondritis dissecans of the capitellum and a loose body in the anterior compartment. Arthroscopic removal is indicated because symptoms referable to the loose body are present. Baumgarten TE: Osteochondritis dissecans of the capitellum. Sports Med Arthroscopy Rev 1995;3:219-223.

Question 13

A 42-year-old patient has had painful inferior subluxation of the glenohumeral joint following a recent cerebrovascular accident (CVA). Figure 34 shows the AP radiograph of the shoulder. Management should consist of

Shoulder 2000 Practice Questions: Set 3 (Solved) - Figure 11

Explanation

Following a CVA and with the resumption of upright posture, downward subluxation of the glenohumeral joint may occur. Although usually painless, some patients may report pain secondary to stretching of the brachial plexus. This is the result of flaccid paralysis of the deltoid muscle, and it will persist until some motor tone or spasticity returns to the shoulder girdle musculature. Early sling support and range-of-motion exercises to prevent contracture will provide the best relief. Surgical procedures are not indicated. Braun RM, Botte MJ: Treatment of shoulder deformity in acquired spasticity. Clin Orthop 1999;368:54-65.

Question 14

A 50-year-old man who underwent an arthroscopic rotator cuff repair 5 days ago now returns for an early postoperative follow-up because of increasing pain in his shoulder. He reports increasing malaise and has a low-grade fever. Examination reveals no redness or swelling, but he has scant serous drainage from the posterior portal. An emergent Gram stain is positive for gram-positive cocci. The next most appropriate step in management should consist of

Explanation

An infection of the shoulder is considered a surgical emergency unless there are medical reasons that a patient cannot be taken to the operating room. If cultures of wound drainage are in question, then an aspiration should be done emergently, not several days later. The hallmark of infection in any major joint is increasing pain out of proportion to what is expected. Drainage occurring 1 to 2 days after an arthroscopic procedure is not normal, and it should be aggressively treated. Delay in diagnosis can result in sepsis and on a delayed basis, postinfectious arthritis. Both the glenohumeral joint and the subacromial space require debridement and irrigation, followed by antibiotics after both areas are cultured. Mansat P, Cofield RH, Kersten TE, Rowland CM: Complications of rotator cuff repair. Orthop Clin North Am 1997;28:205-213. Settecerri JJ, Pitner MA, Rock MG, Hanssen AD, Cofield RH: Infection after rotator cuff repair. J Shoulder Elbow Surg 1999;8:1-5. Ward WG, Eckardt JJ: Subacromial/subdeltoid bursa abscesses: An overlooked diagnosis. Clin Orthop 1993;288:189-194.

Question 15

A 42-year-old man who is right-hand dominant injured his right shoulder when he fell from a ladder onto his outstretched arm 1 hour ago. Radiographs reveal a two-part greater tuberosity anterior fracture-dislocation. Initial management should consist of

Explanation

Greater tuberosity anterior fractures associated with anterior glenohumeral dislocations respond very well to closed methods in the majority of patients. Closed reduction of the glenohumeral joint often anatomically reduces the greater tuberosity into its cancellous bed, without the need for open fixation or cuff repair. Once closed reduction of the joint is performed, tuberosity displacement and joint articulation should be evaluated radiographically with AP and scapular lateral views as well as an axillary view. The axillary view will not only definitively show the joint articulation but also demonstrate posterior displacement of the greater tuberosity missed on the AP and lateral views. If no or minimal (5 mm) displacement is found, then nonsurgical management consisting of a sling and gentle passive range-of-motion exercises can be instituted. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.

Question 16

A 19-year-old man who plays college volleyball undergoes a routine preparticipation physical examination. Figure 35 shows a posterior view of his dominant shoulder. An electromyogram shows that this is a chronic injury, and an MRI scan shows no abnormalities. The best course of action should be

Shoulder 2000 Practice Questions: Set 3 (Solved) - Figure 12

Explanation

Isolated palsy of the infraspinatus portion of the suprascapular nerve is common in volleyball players and is seen frequently in the throwing arm of baseball players. The exact cause is not known, but it may be the result of either tethering or traction on the nerve at the spinoglenoid notch. Synovial cysts in the spinoglenoid notch also can be a cause, but the patient's negative MRI findings rule out that entity. Because many isolated nerve palsies of the infraspinatus branch are asymptomatic, initial management should always be nonsurgical. Surprisingly, many athletes with this injury can participate fully in sports. Surgical treatment with decompression at the notch is unpredictable and generally is indicated only if nonsurgical management fails. Ferretti A, Cerullo G, Russo G: Suprascapular neuropathy in volleyball players. J Bone Joint Surg Am 1987;69:260-263.

Question 17

A 59-year-old construction worker who is right-hand dominant has had right shoulder pain for the past 9 months with no history of injury. Nonsurgical management consisting of two cortisone injections, physical therapy for 3 months, and nonsteroidal anti-inflammatory drugs has failed to provide lasting relief. Examination reveals tenderness over the acromioclavicular (AC) joint and over the subacromial bursa. He has positive Neer and Hawkins impingement signs and AC joint pain with adduction of the shoulder. Radiographs are shown in Figures 36a and 36b. An MRI scan reveals an intact rotator cuff. Management should now consist of

Explanation

Because the patient has clinical and radiographic signs of AC arthritis and subacromial impingement, the treatment of choice is anterior acromioplasty and distal clavicle excision. Arthroscopic acromioplasty alone would not address the AC arthritis. The rotator cuff is intact; therefore, rotator cuff repair is not indicated. An open Mumford procedure would address the AC arthritis only and not the impingement symptoms. Immobilization might lead to stiffness of the shoulder and is not recommended for treating impingement.

Question 18

What three structures are considered the primary constraints necessary for elbow stability?

Explanation

The three primary constraints necessary for elbow stability in all directions are the ulnar part of the lateral collateral ligament (also called the lateral ulnar collateral ligament), the anterior band of the medial collateral ligament, and the coronoid. The radial head and capsule are secondary constraints to elbow instability. Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 283-294.

Question 19

A 68-year-old woman has been progressing slowly after undergoing humeral head replacement for a four-part fracture 3 months ago. She has not regained active elevation, she feels an audible clunk on attempting elevation, and she reports pain and weakness. She used a sling for 2 weeks in the immediate postoperative period. Radiographs are shown in Figure 37a through 37c. Management should consist of

Explanation

Immediate repair of the tuberosity and rotator cuff is recommended on identifying the avulsion or nonunion. Revising the humeral component to increase tension and length will overtighten the cuff and increase the chance of tuberosity pull-off. The glenoid is uninvolved and should not be replaced. Attempts to strengthen the rotator cuff will be unsuccessful because the insertions are no longer attached to the humerus when the tuberosities avulse. Brown TD, Bigliani LU: Complications with humeral head replacement. Orthop Clin North Am 2000;31:77-90.

Question 20

What is the most important feature in choosing an outcome instrument to assess shoulder disorders?

Explanation

There has been a recent increase in the use of outcome instruments to document and measure effects of treatment of medical conditions, including shoulder disorders. The most important feature of an instrument is whether it actually measures what it purports to measure; this is defined as its validity. Leggin BG, Iannotti JP: Shoulder outcome measurement, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams and Wilkins, 1999, p 1027.

Question 21

Figure 38 shows the radiograph of a 16-year-old wrestler who injured his elbow when he was thrown to the mat by his opponent. To minimize additional trauma to the medial soft tissues, the elbow should be reduced in

Shoulder 2000 Practice Questions: Set 3 (Solved) - Figure 18

Explanation

The elbow dislocates by a three-dimensional movement of supination and valgus during flexion. Additional trauma during reduction is minimized by recreating the deformity and reducing the elbow in supination. The actual maneuver includes full supination (actually hypersupination) of the elbow in a valgus position. This is followed by pushing the olecranon distally in line with the long axis of the ulna while swinging the elbow into varus, and then relaxing the supination torque. Postreduction stability is enhanced in pronation, except when the soft-tissue disruption is extensive. O'Driscoll SW: Elbow dislocations, in Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, PA, WB Saunders, 1993, p 414.

Question 22

In patients older than age 40 years who sustain a first-time anterior dislocation of the shoulder, prolonged morbidity is most commonly associated with

Explanation

In the study done by Pevny and associates, 35% of patients older than age 40 years sustained rotator cuff tears and 8% had axillary nerve palsies. All of the patients with axillary nerve palsy also had rotator cuff tears. Imaging of the rotator cuff is indicated in this age group. The incidence of recurrent instability in patients older than age 40 years is 10% to 15%. Pevny T, Hunter RE, Freeman JR: Primary traumatic anterior shoulder dislocation in patients 40 years of age and older. Arthroscopy 1998;14:289-294. Sonnabend DH: Treatment of primary anterior shoulder dislocation in patients older than 40 years of age: Conservative versus operative. Clin Orthop 1994;304:74-77.

Question 23

Figure 39 shows the AP radiograph of a 62-year-old man with degenerative osteoarthritis secondary to trauma. History reveals that he underwent total elbow arthroplasty 3 years ago. He continues to report instability and constant pain. A complete work-up, including aspiration and cultures, is negative. Treatment should consist of removal of the components and

Shoulder 2000 Practice Questions: Set 3 (Solved) - Figure 19

Explanation

An unconstrained prosthesis dislocation is a disconcerting problem that is not easily resolved; however, revision to a semiconstrained prosthesis would best achieve both pain relief and stability. Removal of the components and distraction arthroplasty or conversion to a resection arthroplasty are options, but the results would be unpredictable with regards to pain relief, postoperative motion, or elbow stability. Arthrodesis is poorly tolerated. With revision to another unconstrained prosthesis, there is the risk of continued redislocation because of chronic ligamentous insufficiency. Linscheid RL: Resurfacing elbow replacement arthroplasty: Rationale, technique and results, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 602-610.

Question 24

A 67-year-old woman undergoes a revision total shoulder arthroplasty for replacement of a loose glenoid component. Examination in the recovery room reveals absent voluntary deltoid and triceps contraction, weakness of wrist and thumb extension, and absent sensation in the palmar aspect of all fingertips and the radial forearm. The next most appropriate step in management should consist of

Explanation

Neurologic injury after shoulder replacement is relatively uncommon, occurring in 4% of shoulders in one large series. The importance of identifying and protecting the musculocutaneous and axillary nerves cannot be overemphasized; it is especially critical during revision arthroplasty when the normal anatomic relationships have been distorted. The long deltopectoral approach leaving the deltoid attached to the clavicle was found to be significant in the development of postoperative neurologic complications. A correlation was found between surgical time and postoperative neurologic complications, with long surgical times being associated with more neurologic complications. The presumed mechanism of injury is traction on the plexus that occurs during the surgery. A neurologic injury after total shoulder arthroplasty usually does not interfere with the long-term outcome of the arthroplasty itself; it is best managed by protective measures with passive range of motion of the involved extremity. Wirth MA, Rockwood CA Jr: Complications of shoulder arthroplasty. Clin Orthop 1994;307:47-69.

Question 25

Figure 40 shows the radiograph of a 16-year-old wrestler who injured his elbow when he was thrown to the mat by his opponent. Closed reduction is readily accomplished, and the elbow seems stable. Management should now consist of application of a splint for

Shoulder 2000 Practice Questions: Set 3 (Solved) - Figure 20

Explanation

Flexion contractures are the most common complication of elbow dislocations. About 15% of patients lose more than 30 degrees of flexion. The risk of contracture is proportional to the duration of immobilization. Elbows should be moved within the first few days after reduction. The splinting is for comfort and protection only while the pain subsides. Mehlhoff TL, Noble PC, Bennett JB, Tullos HS: Simple dislocation of the elbow in the adult: Results after closed treatment. J Bone Joint Surg Am 1988;70:244-249. Linscheid RL, O'Driscoll SW: Elbow dislocations, in Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, PA, WB Saunders, 1993, pp 441-452. O'Driscoll SW, Jupiter JB, King GJ, Hotchkiss RN, Morrey BF: The unstable elbow. Instr Course Lect 2001;50:89-102.

Question 26

A 75-year-old man presents with chronic right shoulder pain and an inability to actively elevate his arm above 45 degrees. Radiographs demonstrate an acromiohumeral distance of 3 mm. MRI reveals massive, retracted tears of the supraspinatus and infraspinatus with grade 4 fatty infiltration, while the subscapularis and deltoid are intact. What is the most appropriate surgical treatment?

Explanation

Reverse total shoulder arthroplasty is the treatment of choice for elderly patients with cuff tear arthropathy or massive irreparable rotator cuff tears with pseudoparalysis. Anatomic TSA is contraindicated due to the deficient rotator cuff, which would lead to eccentric glenoid wear.

Question 27

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

Explanation

The open Latarjet procedure (coracoid transfer) is indicated for recurrent anterior shoulder instability in patients with critical glenoid bone loss, typically defined as greater than 20-25%. Arthroscopic soft tissue repair alone has a highly unacceptable failure rate in this scenario.

Question 28

Which of the following radiographic findings is the most reliable predictor of subsequent humeral head ischemia (avascular necrosis) following a severe proximal humerus fracture?

Explanation

A medial calcar hinge disruption and a short metaphyseal head extension (less than 8 mm) are the most reliable predictors of humeral head ischemia. This reflects disruption of the primary blood supply from the ascending branch of the anterior humeral circumflex artery and capsular vessels.

Question 29

A 28-year-old professional baseball pitcher presents with posterior shoulder pain. MRI arthrogram shows undersurface fraying of the posterior supraspinatus and posterosuperior labrum. This pathology is primarily exacerbated by which of the following shoulder positions?

Explanation

This describes internal impingement, common in overhead throwing athletes. It occurs during late cocking and early acceleration, where the shoulder is in extreme abduction and external rotation, pinching the posterosuperior labrum and articular-sided rotator cuff.

Question 30

During the physical examination of a 55-year-old man with a suspected rotator cuff tear, the examiner asks the patient to place the palm of his hand on his contralateral shoulder and attempts to externally rotate the patient's hand while the patient resists. Which specific structure is best isolated by this test?

Explanation

This describes the 'bear-hug' test, which is highly sensitive and specific for evaluating tears of the upper portion of the subscapularis tendon. The lift-off test is generally more specific to the lower subscapularis.

Question 31

A 35-year-old man presents after a seizure with a locked posterior shoulder dislocation. CT scan demonstrates an anteromedial humeral head defect (reverse Hill-Sachs lesion) involving 35% of the articular surface. The dislocation is irreducible closed. What is the most appropriate surgical intervention?

Explanation

For reverse Hill-Sachs lesions involving 20% to 40% of the articular surface, transfer of the lesser tuberosity (with or without the subscapularis tendon) into the defect is the standard treatment (modified McLaughlin procedure). Defects >40-50% generally require arthroplasty.

Question 32

A 45-year-old woman undergoes arthroscopy for persistent anterior shoulder pain. The surgeon notes medial subluxation of the long head of the biceps tendon and a tear of the coracohumeral ligament. Which of the following additional structures must be torn to allow this biceps subluxation?

Explanation

The biceps pulley stabilizes the long head of the biceps in the bicipital groove. It is primarily formed by the superior glenohumeral ligament (SGHL) and the coracohumeral ligament (CHL), along with the upper fibers of the subscapularis.

Question 33

During an open Latarjet procedure, the surgeon inadvertently places a self-retaining medial retractor deep to the conjoined tendon and applies excessive traction. Which of the following nerves is at greatest risk of injury from this maneuver?

Explanation

The musculocutaneous nerve typically enters the coracobrachialis muscle 5 to 8 cm distal to the tip of the coracoid. Retractors placed medially and distally to the conjoined tendon place this nerve at significant risk.

Question 34

A 68-year-old woman with severe osteoporosis sustains a 4-part proximal humerus fracture with a head-split component. She is functionally independent and active. What is the most appropriate treatment to optimize her functional outcome and minimize complications?

Explanation

In elderly patients with poor bone quality and complex fractures (like a 4-part head-split), reverse total shoulder arthroplasty provides a more reliable and predictable functional outcome compared to ORIF or hemiarthroplasty, primarily because it does not rely on tuberosity healing for overhead function.

Question 35

In evaluating a standard anteroposterior radiograph of the shoulder in a patient with chronic rotator cuff disease, what is the earliest radiographic sign indicative of rotator cuff tear arthropathy?

Explanation

The earliest radiographic manifestation of massive rotator cuff tearing and impending arthropathy is superior migration of the humeral head, defined by an acromiohumeral distance (AHD) of less than 7 mm. Acetabularization and femoralization occur in later stages (Hamada classification).

Question 36

A 40-year-old construction worker presents with persistent shoulder pain despite 6 months of nonoperative management. MRI reveals an articular-sided partial tear of the supraspinatus tendon involving 60% of the tendon footprint depth (PASTA lesion). What is the recommended surgical management?

Explanation

For partial rotator cuff tears involving greater than 50% of the tendon footprint depth, surgical repair (either by completion of the tear and repair or a transtendon repair) is indicated. Debridement alone is inadequate for tears >50%.

Question 37

The concept of the 'glenoid track' is used to evaluate anterior shoulder instability. Which of the following statements correctly defines an 'off-track' Hill-Sachs lesion?

Explanation

An off-track Hill-Sachs lesion occurs when its medial margin lies medial to the medial border of the glenoid track. This indicates that the lesion will engage the anterior glenoid rim during abduction and external rotation, typically necessitating a remplissage or bone block.

Question 38

A 42-year-old man is undergoing an open subpectoral biceps tenodesis. The surgeon makes an incision in the axillary fold and exposes the intertubercular groove. Which nerve is most at risk of injury during medial retraction of the conjoint tendon in this approach?

Explanation

During a subpectoral biceps tenodesis, vigorous medial retraction of the short head of the biceps and coracobrachialis (conjoint tendon) puts the musculocutaneous nerve at high risk, as it penetrates the coracobrachialis nearby.

Question 39

A 25-year-old man presents with an acute anterior shoulder dislocation. After reduction, an MR arthrogram reveals disruption of the inferior glenohumeral ligament at its insertion onto the anatomic neck of the humerus, with contrast leaking into the axillary pouch. What is this lesion called?

Explanation

A HAGL (Humeral Avulsion of the Glenohumeral Ligament) lesion involves the avulsion of the IGHL complex from the humeral neck. This creates a classic 'J-sign' on MR arthrography as the normal U-shaped axillary pouch is disrupted.

Question 40

A 58-year-old man with a massive, irreparable posterosuperior rotator cuff tear is scheduled for a latissimus dorsi tendon transfer. For this procedure to be successful in restoring active forward elevation, which of the following muscles MUST be functionally intact to provide a balanced force couple?

Explanation

A successful latissimus dorsi transfer for a massive posterosuperior cuff tear requires an intact and functioning subscapularis to maintain the anterior-posterior force couple of the shoulder, keeping the humeral head centered on the glenoid.

Question 41

A 22-year-old elite collegiate baseball pitcher is diagnosed with an isolated Type II SLAP tear via MRI arthrogram. He has significant glenohumeral internal rotation deficit (GIRD) on exam. What is the most appropriate initial management?

Explanation

First-line treatment for an isolated Type II SLAP tear in an overhead throwing athlete, especially with concomitant GIRD, is conservative management. Physical therapy emphasizing posterior capsular stretching (sleeper stretches) and scapular stabilization is highly effective and avoids the stiffness often seen post-SLAP repair.

Question 42

A 28-year-old male volleyball player presents with isolated, painless weakness in external rotation of his dominant shoulder. MRI reveals a paralabral ganglion cyst. At which of the following anatomic locations is the cyst most likely causing nerve compression?

Explanation

A cyst at the spinoglenoid notch compresses the distal suprascapular nerve, causing isolated denervation and atrophy of the infraspinatus (external rotation weakness). Compression at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 43

What is the most frequent hardware-related complication following open reduction and internal fixation of a proximal humerus fracture using a locking plate?

Explanation

Intra-articular screw penetration (primary or secondary to screw cut-out from varus collapse) is the most common hardware-related complication of locked plating for proximal humerus fractures, occurring in up to 10-20% of cases.

Question 44

During biomechanical testing of the glenohumeral joint, which capsuloligamentous structure is the primary restraint to anterior translation when the arm is positioned in 90 degrees of abduction and maximum external rotation?

Explanation

The anterior band of the inferior glenohumeral ligament (IGHL) complex is the primary static restraint to anterior, inferior, and posterior translation of the humeral head at 90 degrees of abduction.

Question 45

A 52-year-old woman sustains an acute anterior shoulder dislocation. After a successful closed reduction in the emergency department, she complains of persistent pain and is completely unable to actively abduct her arm. Axillary nerve sensation is intact. What is the most likely associated injury?

Explanation

In patients older than 40 years, there is a high incidence (ranging from 30% to 80% in older cohorts) of concomitant rotator cuff tears following acute anterior shoulder dislocations. Persistent inability to abduct after reduction should prompt immediate advanced imaging (MRI or US).

Question 46

A 22-year-old competitive rugby player presents with recurrent anterior shoulder dislocations. CT scan reveals 25% anterior glenoid bone loss. What is the most appropriate surgical management?

Explanation

In collision athletes with critical anterior glenoid bone loss (>20-25%), an arthroscopic or open Bankart repair has unacceptably high failure rates. A Latarjet procedure (coracoid transfer) is indicated to restore anterior stability via its triple-blocking effect.

Question 47

A 65-year-old man presents with chronic shoulder weakness and a massive, retracted rotator cuff tear. Which of the following preoperative MRI findings is the strongest contraindication to a primary tendon repair?

Explanation

High-grade (Goutallier 3 or 4) fatty infiltration and muscle atrophy indicate irreversible muscle degeneration. Attempting primary repair in these settings is associated with extremely high structural failure rates.

Question 48

A 55-year-old woman sustains a proximal humerus fracture. According to Hertel's criteria, which radiographic factor is the most reliable predictor of subsequent humeral head ischemia?

Explanation

Hertel described predictors of humeral head ischemia, which include a short calcar segment (metaphyseal head extension < 8 mm), disruption of the medial hinge, and a basicervical (anatomic neck) fracture pattern.

Question 49

When evaluating a patient with recurrent anterior shoulder instability and bipolar bone loss, a Hill-Sachs lesion is considered 'off-track' (engaging) under which of the following conditions?

Explanation

The glenoid track concept determines engagement. A Hill-Sachs lesion is 'off-track' if its medial margin extends further medial than the intact glenoid track, meaning it will engage the anterior glenoid rim during abduction and external rotation.

Question 50

A 45-year-old laborer with an intact subscapularis presents with persistent pain and pseudoparalysis of external rotation due to a massive, irreparable posterosuperior rotator cuff tear. Which tendon transfer is most appropriate?

Explanation

Latissimus dorsi or lower trapezius transfers are indicated to restore active external rotation and forward elevation in younger patients with massive, irreparable posterosuperior tears, provided the subscapularis and deltoid are intact.

Question 51

A 75-year-old female sustains a comminuted 4-part proximal humerus fracture with severe osteoporosis and poor tuberosity bone quality. What is the most reliable surgical option to restore active elevation?

Explanation

Reverse total shoulder arthroplasty is favored in the elderly with 4-part fractures and poor bone quality because functional outcomes rely on deltoid function rather than reliable tuberosity healing.

Question 52

A 30-year-old weightlifter presents with posterior shoulder pain during bench presses. Examination reveals a positive jerk test. MRI confirms a posterior labral tear. What is the most appropriate initial management?

Explanation

Initial management for posterior shoulder instability is nonoperative, focusing on comprehensive physical therapy to strengthen the dynamic posterior stabilizers (posterior cuff, periscapular muscles, and posterior deltoid).

Question 53

A patient presents with isolated weakness of external rotation but normal active forward elevation. Examination reveals isolated atrophy in the infraspinatus fossa. A paralabral cyst is most likely compressing the suprascapular nerve at which anatomical location?

Explanation

Compression of the suprascapular nerve at the spinoglenoid notch affects only the motor branches to the infraspinatus (external rotation). Compression further proximal at the suprascapular notch would also denervate the supraspinatus.

Question 54

During a deltopectoral approach for a proximal humerus fracture, the axillary nerve must be protected. Which of the following describes its anatomical course relative to the shoulder joint?

Explanation

The axillary nerve runs inferior to the joint capsule and exits the axilla posteriorly through the quadrilateral space. It is particularly at risk during inferior capsular releases or inferior retractor placement.

Question 55

A 28-year-old male with recurrent anterior instability undergoes an MRI arthrogram that shows no Bankart lesion, but reveals an avulsion of the inferior glenohumeral ligament from the humeral neck. What is this lesion termed?

Explanation

Humeral Avulsion of the Glenohumeral Ligament (HAGL) causes recurrent anterior instability. It lacks the typical labral detachment (Bankart) and requires surgical repair to the humeral neck.

Question 56

In a patient with a massive, chronic rotator cuff tear, which structure becomes the primary static restraint to anterosuperior translation of the humeral head?

Explanation

The coracoacromial (CA) ligament acts as the primary restraint to anterosuperior humeral head escape in a rotator cuff deficient shoulder. It should never be routinely sectioned or released in these patients.

Question 57

When performing open reduction and internal fixation of a surgical neck proximal humerus fracture with a locking plate, what is the primary biomechanical advantage of placing inferior medial calcar screws?

Explanation

Placing screws in the inferior medial quadrant of the humeral head (calcar screws) provides crucial structural support, preventing varus collapse and subsequent superior screw cutout through the articular surface.

Question 58

How does an Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) lesion classically differ from a standard Bankart lesion?

Explanation

In an ALPSA lesion, the labroligamentous complex avulses from the glenoid rim but the scapular periosteum remains intact. This allows the torn complex to displace and heal medially on the glenoid neck.

Question 59

A 40-year-old overhead athlete presents with shoulder pain. MRI shows a partial articular-sided supraspinatus tendon avulsion (PASTA) involving 60% of the tendon footprint. If nonoperative management fails, what is the most appropriate surgical treatment?

Explanation

For partial-thickness rotator cuff tears involving greater than 50% of the tendon thickness, surgical completion and repair (or an in situ repair) is indicated due to high progression rates and continued pain with debridement alone.

Question 60

The arthroscopic remplissage procedure, utilized for engaging Hill-Sachs lesions, involves capsulotenodesis of which structures into the humeral defect?

Explanation

Remplissage involves suturing the posterior capsule and the infraspinatus tendon into the Hill-Sachs defect. This converts an intra-articular engaging defect into an extra-articular non-engaging defect.

Question 61

What is the most common complication following open reduction and internal fixation of a proximal humerus fracture using a fixed-angle locking plate?

Explanation

Intra-articular screw penetration is the most common complication of locking plate fixation for proximal humerus fractures, often resulting from post-operative varus collapse or primary over-penetration.

Question 62

During a Superior Capsular Reconstruction (SCR) for a massive irreparable rotator cuff tear, the graft is anchored to the superior glenoid medially. Where is it anchored laterally?

Explanation

In SCR, the dermal or fascia lata graft is secured medially to the superior glenoid and laterally to the greater tuberosity, aiming to restore the superior restraint to humeral head translation.

Question 63

Following an acute anterior shoulder dislocation, a 24-year-old male is unable to actively elevate his arm and reports numbness over the lateral aspect of his shoulder. Which nerve is most likely injured?

Explanation

The axillary nerve is the most frequently injured nerve during anterior shoulder dislocations. It innervates the deltoid and teres minor and provides sensation to the lateral shoulder (superior lateral cutaneous nerve of the arm).

Question 64

A patient is evaluated for anterior shoulder pain. They demonstrate a positive belly-press test and increased passive external rotation. If an MRI confirms a full-thickness subscapularis tear, what associated pathology is most likely to be found?

Explanation

The superior fibers of the subscapularis and the coracohumeral ligament create the medial sling for the biceps tendon. A tear of the subscapularis footprint frequently leads to medial subluxation or dislocation of the long head of the biceps.

Question 65

Recent quantitative anatomic studies have demonstrated that the predominant arterial blood supply to the humeral head is derived from which of the following vessels?

Explanation

Historically, the anterior circumflex humeral artery (arcuate branch) was thought to be the primary supply. However, recent quantitative studies have shown the posterior circumflex humeral artery actually provides the predominant blood supply to the humeral head.

Question 66

A 34-year-old man presents with severe shoulder pain and inability to externally rotate the arm following a generalized seizure. An axillary lateral radiograph is obtained.

Advanced imaging reveals a locked posterior shoulder dislocation with an anteromedial humeral head defect (reverse Hill-Sachs lesion) involving 30% of the articular surface. What is the most appropriate surgical management?

Explanation

A reverse Hill-Sachs lesion involving 20% to 40% of the articular surface is best treated with a McLaughlin procedure or its modification (transfer of the subscapularis tendon or lesser tuberosity into the defect). Defects >40% typically require arthroplasty, while small defects <20% may be stable after reduction alone.

Question 67

A 55-year-old man presents with profound weakness in active internal rotation after a traumatic lifting injury. MRI confirms an isolated, full-thickness, retracted tear of the subscapularis tendon. Which of the following physical examination findings is most specific for this condition?

Explanation

An isolated subscapularis tear results in a loss of the anterior restraint, leading to increased passive external rotation. The lift-off and bear-hug tests would also be positive, but among the choices, asymmetric increased passive external rotation is highly specific for subscapularis deficiency.

Question 68

A 65-year-old woman sustains a displaced proximal humerus fracture after a fall.

According to the Hertel criteria, which of the following radiographic findings is most predictive of developing avascular necrosis of the humeral head?

Explanation

Hertel et al. identified criteria predictive of humeral head ischemia, including a short metaphyseal head extension (calcar length < 8 mm), a disrupted medial hinge, and an anatomic neck fracture pattern. These factors indicate severe disruption of the arcuate branch of the anterior humeral circumflex artery and posterior intraosseous vessels.

Question 69

A 22-year-old collegiate rugby player experiences recurrent anterior shoulder instability. A pre-operative 3D CT scan reveals 27% anterior glenoid bone loss with an "inverted pear" appearance. What is the most appropriate definitive management?

Explanation

Critical anterior glenoid bone loss (typically >20-25%) alters the glenoid shape to an "inverted pear" and is a primary indication for a bony augmentation procedure like the Latarjet. Soft tissue Bankart repairs have an unacceptably high failure rate in the setting of critical bone loss.

Question 70

A 72-year-old woman presents with severe shoulder pain and pseudoparalysis. Radiographs demonstrate advanced cuff tear arthropathy with superior migration of the humeral head. She is scheduled for a reverse total shoulder arthroplasty (RTSA).

The stability and primary functional elevation of this implant rely most heavily on the tension and function of which muscle?

Explanation

A reverse total shoulder arthroplasty medialiizes and distalizes the center of rotation, which increases the moment arm and tension of the deltoid muscle. The deltoid becomes the primary elevator and stabilizer of the shoulder in the absence of a functional rotator cuff.

Question 71

A 40-year-old man sustains a severe proximal humerus fracture and presents with decreased sensation over the lateral aspect of his shoulder. Assuming the nerve supplying this area is injured, which of the following muscles is most likely to exhibit denervation weakness?

Explanation

Decreased sensation over the lateral shoulder (regimental badge area) indicates axillary nerve injury. The axillary nerve innervates both the deltoid and the teres minor muscles.

Question 72

A 28-year-old overhead athlete is diagnosed with a Type II SLAP (Superior Labrum Anterior and Posterior) tear on MR arthrogram. Which of the following best describes the anatomic pathology of a Type II SLAP lesion?

Explanation

A Type II SLAP lesion involves the detachment of the superior labrum and the long head of the biceps anchor from the supraglenoid tubercle. Type I is fraying, Type III is a bucket-handle tear with an intact anchor, and Type IV is a bucket-handle tear extending into the biceps tendon.

Question 73

An MRI of a 45-year-old recreational tennis player reveals a partial articular-sided supraspinatus tendon avulsion (PASTA lesion). The tear is estimated to involve 65% of the tendon footprint thickness. Nonoperative management has failed. What is the most appropriate surgical intervention?

Explanation

For partial-thickness articular-sided rotator cuff tears that involve >50% of the tendon footprint, the standard of care is to either perform a transtendon repair or complete the tear to a full-thickness defect followed by standard repair. Debridement alone is indicated for tears <50%.

Question 74

A 25-year-old man undergoes an arthroscopic anterior stabilization procedure. Intraoperatively, an engaging Hill-Sachs lesion is identified, and the surgeon decides to perform an arthroscopic remplissage. This procedure involves securing which of the following structures into the humeral head defect?

Explanation

An arthroscopic remplissage (French for "to fill") addresses an engaging Hill-Sachs lesion by tenodesing the infraspinatus tendon and the posterior joint capsule into the bony defect. This prevents the defect from engaging the anterior glenoid rim during external rotation and abduction.

Question 75

A 21-year-old collegiate baseball pitcher complains of posterior shoulder pain during the late cocking phase of throwing. Physical examination reveals a positive apprehension test, but pain is completely relieved with the relocation test. MR arthrogram demonstrates posterior/superior labral fraying and a partial articular-sided supraspinatus tear. What is the most likely diagnosis?

Explanation

Internal impingement occurs in overhead athletes during the late cocking phase (abduction and maximal external rotation), causing the undersurface of the supraspinatus/infraspinatus to impinge against the posterosuperior labrum. It classically presents with posterior pain relieved by the relocation test.

Question 76

A 68-year-old man sustains a minimally displaced 2-part surgical neck fracture of the proximal humerus and is treated nonoperatively.

To minimize the risk of adhesive capsulitis while ensuring fracture stability, when is the optimal time to initiate early passive range of motion exercises?

Explanation

For minimally displaced proximal humerus fractures, early gentle passive range of motion should typically begin at 7 to 14 days once initial pain subsides. Prolonged immobilization beyond 2-3 weeks significantly increases the risk of severe shoulder stiffness and adhesive capsulitis.

Question 77

A 19-year-old female competitive swimmer presents with bilateral shoulder pain and a sensation that her shoulders "slide out of place." Examination shows generalized hyperlaxity, a positive sulcus sign that does not reduce with external rotation, and normal rotator cuff strength. What is the most appropriate initial management?

Explanation

The patient has multidirectional instability (MDI), characterized by symptomatic generalized laxity and a positive sulcus sign. The first-line and most effective initial treatment is a prolonged course (typically 6 months) of targeted physical therapy emphasizing periscapular and rotator cuff strengthening.

Question 78

A 50-year-old woman undergoes ORIF with a locking plate for a 3-part proximal humerus fracture.

Six weeks postoperatively, she reports a grinding sensation and mechanical block during elevation. Radiographs show varus settling of the humeral head. What is the most common hardware-related complication necessitating reoperation in this scenario?

Explanation

Intra-articular screw penetration is the most frequent hardware-related complication following locking plate fixation of proximal humerus fractures. It typically occurs secondary to varus collapse or settling of the humeral head fragment over the fixed-angle screws.

Question 79

A 38-year-old weightlifter presents with vague posterior shoulder pain and isolated weakness in external rotation. Abduction strength is fully preserved. MRI demonstrates a paralabral cyst located strictly within the spinoglenoid notch. Which of the following muscles is most likely selectively denervated?

Explanation

The suprascapular nerve innervates the supraspinatus before passing through the spinoglenoid notch to innervate the infraspinatus. A cyst isolated to the spinoglenoid notch will compress the distal branches, resulting in isolated infraspinatus weakness (decreased external rotation) while sparing supraspinatus function.

Question 80

A 30-year-old male powerlifter feels a "pop" in his anterior axilla while bench pressing. Examination reveals an asymmetric anterior axillary fold and weakness in internal rotation. MRI confirms a complete avulsion of the pectoralis major tendon from the humerus. Which of the following statements regarding the relevant anatomy and repair is TRUE?

Explanation

The pectoralis major consists of a clavicular and sternocostal head. The sternocostal head undergoes a 180-degree twist such that its fibers insert deep and proximal to the superficial and distal clavicular fibers. Surgical repair in active individuals significantly improves internal rotation strength and cosmesis.

Question 81

A 60-year-old male with an irreparable massive rotator cuff tear (supraspinatus and infraspinatus) without advanced glenohumeral arthritis undergoes a superior capsular reconstruction (SCR) using dermal allograft. The primary biomechanical goal of this procedure is to:

Explanation

Superior capsular reconstruction (SCR) is designed to restore the superior constraint of the glenohumeral joint in the setting of an irreparable supraspinatus tear. By anchoring the graft between the superior glenoid and the greater tuberosity, it statically prevents superior migration of the humeral head.

Question 82

During open repair of a massive rotator cuff tear, the surgeon meticulously decorticates the greater tuberosity to enhance biological healing. To fully restore native biomechanics, the healing tissue must eventually replicate the normal enthesis. The native, direct rotator cuff tendon insertion onto the bone consists of how many distinct histological zones?

Explanation

The normal native rotator cuff insertion is a direct fibrocartilaginous enthesis consisting of four distinct histological transition zones: tendon, uncalcified fibrocartilage, calcified fibrocartilage, and bone. This gradual transition minimizes stress risers at the insertion site.

Question 83

A 68-year-old woman sustains a severely displaced 4-part proximal humerus fracture. Radiographic evaluation demonstrates a calcar segment of 4 mm and a completely disrupted medial hinge. According to the Hertel criteria, what is the most reliable management option to ensure a predictable functional recovery given her risk of avascular necrosis?

Explanation

Hertel criteria for high risk of humeral head ischemia include a short calcar segment (<8 mm), a disrupted medial hinge, and a basicervical fracture pattern. Reverse total shoulder arthroplasty (RTSA) is favored in elderly patients with 4-part fractures at high risk of AVN to provide reliable functional recovery.

Question 84

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

Explanation

Critical glenoid bone loss (>20-25%) in a collision athlete is a contraindication to isolated soft-tissue stabilization. The Latarjet procedure (coracoid transfer) is indicated as it provides a bony block and a dynamic sling effect from the conjoined tendon.

Question 85

A 74-year-old man presents with chronic shoulder pain and inability to actively elevate his arm above 60 degrees. MRI demonstrates a massive, retracted posterosuperior rotator cuff tear with Goutallier stage 4 fatty infiltration of the supraspinatus and infraspinatus. The subscapularis is intact. What is the most appropriate definitive surgical treatment?

Explanation

Reverse total shoulder arthroplasty is the treatment of choice for elderly patients with massive, irreparable rotator cuff tears and pseudoparalysis. Tendon transfers and superior capsular reconstructions require an intact, functioning deltoid and are generally contraindicated in the setting of true pseudoparalysis.

Question 86

A 35-year-old man with a seizure disorder presents with a locked posterior shoulder dislocation. CT scan demonstrates a reverse Hill-Sachs lesion involving 35% of the humeral articular surface. What is the most appropriate surgical management?

Explanation

For reverse Hill-Sachs lesions involving >20-25% of the articular surface, soft tissue or lesser tuberosity transfers are often insufficient. Segmental structural allograft reconstruction is indicated for defects between 25% and 50% to restore articular congruity in young patients.

Question 87

During a physical examination of a patient with suspected rotator cuff pathology, the examiner asks the patient to place the palm of their hand on the opposite shoulder with the elbow anterior to the body, and the examiner applies an upward force to the wrist. Which specific structure is primarily being evaluated?

Explanation

This describes the bear hug test, which is a highly sensitive and specific maneuver for evaluating subscapularis tendon tears. The belly-press and lift-off tests also evaluate the subscapularis.

Question 88

A 28-year-old man sustains an anterior shoulder dislocation with a concomitant greater tuberosity fracture. Following closed reduction, the patient is unable to actively abduct the shoulder and has diminished sensation over the lateral aspect of the shoulder. Injury to which of the following nerves is most likely?

Explanation

The axillary nerve is the most commonly injured nerve in anterior shoulder dislocations, particularly those associated with greater tuberosity fractures. It innervates the deltoid and teres minor and provides sensation to the lateral shoulder via the superior lateral brachial cutaneous nerve.

Question 89

A 24-year-old man with recurrent anterior instability undergoes a preoperative MRI which reveals an "off-track" Hill-Sachs lesion and 10% anterior glenoid bone loss. What is the most appropriate surgical intervention?

Explanation

An "off-track" Hill-Sachs lesion combined with subcritical glenoid bone loss (<20%) is best treated with an arthroscopic Bankart repair combined with a Remplissage (infraspinatus tenodesis into the humeral defect). This combination effectively converts the lesion to an "on-track" state, reducing recurrence risk.

Question 90

Normal tendon-to-bone healing in the rotator cuff footprint is characterized by four distinct histological zones. What is the correct sequence of these zones from the tendon to the bone?

Explanation

The native direct insertion of the rotator cuff transitions through four distinct zones: tendon, uncalcified fibrocartilage, calcified fibrocartilage, and bone. Surgical repair typically heals via a fibrovascular scar rather than recreating this specialized native anatomy.

Question 91

A 45-year-old manual laborer presents with deep shoulder pain and mechanical catching. He has a positive O'Brien test and dynamic labral shear test. MRI arthrogram demonstrates a Type II SLAP tear. After failing 6 months of nonoperative management, what is the most strongly supported surgical recommendation?

Explanation

For a Type II SLAP tear in patients over age 35-40, particularly manual laborers, biceps tenodesis is highly recommended over SLAP repair. Tenodesis yields superior pain relief, lower complication rates, and lower reoperation rates in this demographic.

Question 92

A 55-year-old man underwent open reduction and internal fixation with a locked plate for a 3-part proximal humerus fracture 6 months ago. He now presents with severe shoulder pain and a mechanical clicking sensation during elevation.

What is the most common hardware-related complication that leads to this presentation?

Explanation

Intra-articular screw penetration is the most frequent hardware-related complication after locked plating of proximal humerus fractures. It often results from fracture settling, avascular necrosis, or unrecognized initial over-penetration, leading to secondary chondral damage and mechanical symptoms.

Question 93

A 78-year-old woman presents with chronic right shoulder pain. Radiographs demonstrate superior migration of the humeral head with "acetabularization" of the coracoacromial arch and advanced glenohumeral osteoarthritis. Which classification system specifically stages these radiographic findings in the setting of rotator cuff arthropathy?

Explanation

The Hamada classification stages the radiographic progression of massive rotator cuff tears. Stage 4a/4b and Stage 5 involve severe glenohumeral arthritis and acetabularization of the acromion, characterizing advanced rotator cuff tear arthropathy.

Question 94

A 21-year-old collegiate baseball pitcher complains of posterior shoulder pain during the late cocking phase of throwing. Physical exam reveals a glenohumeral internal rotation deficit (GIRD) of 25 degrees. What is the primary pathoanatomy associated with internal impingement in this athlete?

Explanation

Internal impingement occurs during the late cocking phase (abduction and external rotation), leading to pathologic contact between the articular side of the posterosuperior rotator cuff and the posterosuperior glenoid labrum. GIRD is frequently an associated finding due to posterior capsular contracture.

Question 95

A 30-year-old male weightlifter felt a "pop" in his anterior axilla while performing a heavy bench press. Exam shows loss of the normal anterior axillary fold contour. When considering the relevant surgical anatomy for repair, the sternal head of the pectoralis major tendon normally inserts in what position relative to the clavicular head?

Explanation

The pectoralis major tendon twists 180 degrees before its insertion onto the lateral lip of the bicipital groove. Consequently, the inferior (sternocostal) fibers insert proximal and deep (posterior) to the superior (clavicular) fibers.

Question 96

A 19-year-old female gymnast presents with bilateral multidirectional shoulder instability. She has failed 9 months of dedicated physical therapy emphasizing periscapular stabilization. If surgical intervention is pursued, what is the most historically validated "gold standard" procedure?

Explanation

In patients with true multidirectional instability (MDI) who fail extensive conservative management, an open or arthroscopic inferior capsular shift is the procedure of choice to reduce overall capsular volume. Thermal capsulorrhaphy is obsolete due to high failure rates and chondrolysis.

Question 97

A 29-year-old volleyball player presents with insidious onset right shoulder weakness. MRI demonstrates an isolated paralabral cyst located in the spinoglenoid notch causing nerve compression. Which of the following clinical findings is most expected?

Explanation

The suprascapular nerve innervates the supraspinatus before traversing the spinoglenoid notch to innervate the infraspinatus. Entrapment at the spinoglenoid notch isolatedly affects the infraspinatus, causing weakness in external rotation while preserving supraspinatus function (abduction).

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

Shoulder Orthopedics MCQs (Set 3): Rotator Cuff, Instability & Proximal Humerus | ABOS Board Review

Key Takeaway

Shoulder Orthopedics MCQs (Set 3): Rotator Cuff, Instability & Proximal Humerus | ABOS Board Review

Chapter Index