AAOS Shoulder MCQs Set 4: Rotator Cuff & Fractures

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

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

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

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

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 24-year-old collegiate rugby player presents with recurrent anterior shoulder instability. A CT scan reveals 26% anterior glenoid bone loss.

What is the most appropriate definitive management?

Explanation

In the setting of critical anterior glenoid bone loss (>20-25%), arthroscopic soft-tissue stabilization has an unacceptably high failure rate. The Latarjet procedure (coracoid transfer) is the gold standard for restoring anterior stability through a triple-blocking effect.

Question 27

A 45-year-old man presents with severe shoulder pain and restricted external rotation following a grand mal seizure. Radiographs confirm a locked posterior shoulder dislocation with a reverse Hill-Sachs lesion involving 35% of the articular surface. Which of the following is the most appropriate surgical treatment?

Explanation

For locked posterior dislocations with an anteromedial humeral head defect (reverse Hill-Sachs) between 20% and 40%, a modified McLaughlin procedure (lesser tuberosity transfer) is indicated. Defects >40-50% generally require arthroplasty.

Question 28

A 32-year-old competitive volleyball player reports vague posterior shoulder pain and weakness with external rotation. Examination shows isolated atrophy of the infraspinatus. MRI reveals a multiloculated cystic structure at the spinoglenoid notch.

What associated intra-articular pathology is most likely present?

Explanation

Spinoglenoid notch cysts causing isolated suprascapular nerve entrapment and infraspinatus atrophy are highly associated with posterosuperior labral (SLAP) tears. Repairing the labral tear allows decompression of the paralabral cyst.

Question 29

A 75-year-old man presents with chronic right shoulder pain and an inability to actively elevate his arm above 40 degrees. Passive range of motion is full. Radiographs reveal superior migration of the humeral head with an acromiohumeral interval of 3 mm. MRI confirms a massive, retracted tear of the supraspinatus and infraspinatus with Goutallier stage 4 fatty infiltration. His deltoid is functional. What is the most appropriate definitive management?

Explanation

Reverse total shoulder arthroplasty is the treatment of choice for elderly patients with rotator cuff arthropathy and pseudoparalysis. It relies on a functional deltoid muscle to elevate the arm, bypassing the deficient rotator cuff.

Question 30

A 22-year-old collegiate linebacker presents with recurrent anterior shoulder instability. He has had 5 dislocations over the past two seasons. A 3D CT scan reveals 25% anterior glenoid bone loss. What is the most appropriate surgical management?

Explanation

The Latarjet procedure (coracoid transfer) is indicated for anterior shoulder instability in the setting of critical glenoid bone loss (>20-25%). Soft tissue repairs alone have an unacceptably high failure rate in this scenario.

Question 31

A 45-year-old man presents to the emergency department with severe left shoulder pain following a generalized tonic-clonic seizure. On examination, his arm is locked in internal rotation, and he has 0 degrees of external rotation. Radiographs demonstrate a 'lightbulb' sign on the AP view. A CT scan reveals an anteromedial humeral head impaction fracture involving 30% of the articular surface. Which of the following is the most appropriate surgical treatment?

Explanation

This patient has a locked posterior shoulder dislocation with a reverse Hill-Sachs defect of 30%. The modified McLaughlin procedure, which involves transferring the lesser tuberosity and subscapularis into the defect, is indicated for defects between 25% and 40%.

Question 32

A 68-year-old woman falls onto her outstretched arm and sustains a displaced 4-part proximal humerus fracture. She has a history of severe osteoporosis. Her tuberosities are widely displaced, and the anatomic neck is fractured. Which of the following factors is most predictive of humeral head avascular necrosis in this patient?

Explanation

Predictors of avascular necrosis after proximal humerus fractures include a disrupted medial hinge, a short calcar segment (<8 mm), and anatomic neck fractures. These disrupt the blood supply from the ascending branches of the anterior humeral circumflex artery.

Question 33

A 55-year-old man presents with anterior shoulder pain and weakness following a fall while water skiing. On physical examination, he has full passive range of motion. When the patient places the palm of his hand on his opposite shoulder, he is unable to resist the examiner pulling the hand away anteriorly. Which tendon is most likely injured?

Explanation

The Bear Hug test is highly sensitive and specific for subscapularis tears. The patient's inability to maintain the hand on the opposite shoulder against resistance indicates subscapularis dysfunction.

Question 34

A 32-year-old elite volleyball player complains of vague posterior shoulder pain and weakness with external rotation. Examination shows isolated atrophy of the infraspinatus fossa with normal supraspinatus bulk. Which of the following is the most likely etiology?

Explanation

Entrapment of the suprascapular nerve at the spinoglenoid notch causes isolated infraspinatus weakness and atrophy, often secondary to a paralabral cyst. Entrapment at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 35

A 24-year-old rock climber undergoes diagnostic arthroscopy for recurrent anterior shoulder instability. The surgeon identifies a deep, engaging posterolateral humeral head defect. To prevent this lesion from engaging the anterior glenoid rim during abduction and external rotation, the surgeon performs a Remplissage. Which structure is tenodesed into the humeral defect?

Explanation

The Remplissage procedure involves capsulotenodesis of the infraspinatus tendon and posterior capsule into an engaging Hill-Sachs defect. This converts an intra-articular defect into an extra-articular one and acts as a posterior tether.

Question 36

A 40-year-old man presents with right shoulder weakness 3 weeks after a motor vehicle collision. He complains of pain at the base of his neck and shoulder. On physical examination, forward flexion of the arm against resistance results in medial translation and prominent winging of the scapula. Injury to which of the following nerves is the most likely cause?

Explanation

Injury to the long thoracic nerve results in serratus anterior palsy, characterized by medial winging of the scapula. Spinal accessory nerve injury affecting the trapezius causes lateral winging.

Question 37

A 65-year-old man sustains a traumatic anterior shoulder dislocation. After closed reduction in the emergency department, he presents 2 weeks later complaining of inability to raise his arm. He has no numbness or tingling. Radiographs are normal. Physical examination reveals active forward elevation to 45 degrees and a positive drop arm test. What is the most appropriate next step in management?

Explanation

Older adults (>60 years) have a high incidence of massive rotator cuff tears associated with anterior shoulder dislocations. Persistent weakness after reduction in this age group necessitates advanced imaging like MRI or ultrasound to evaluate the rotator cuff.

Question 38

A 28-year-old man falls onto his lateral shoulder and sustains a closed midshaft clavicle fracture. Which of the following is considered an indication for operative fixation to prevent nonunion and symptomatic malunion?

Explanation

Operative indications for midshaft clavicle fractures include 100% displacement, shortening greater than 2 cm, z-type comminution, and impending skin breakdown. These factors are strongly associated with higher rates of nonunion.

Question 39

A 35-year-old male bodybuilder feels a sudden pop in his anterior axilla while performing a heavy bench press. He presents with ecchymosis, swelling, and a loss of the anterior axillary fold. MRI confirms a complete rupture of the pectoralis major tendon. Where does this rupture most commonly occur?

Explanation

Pectoralis major ruptures most frequently occur at the sternal head tendon insertion onto the proximal humerus during maximal eccentric contraction. Surgical repair yields the best functional outcomes for active individuals.

Question 40

A 45-year-old recreational tennis player has persistent shoulder pain despite 6 months of conservative management. An MRI arthrogram reveals an articular-sided partial-thickness supraspinatus tendon tear measuring 7 mm in depth (approximately 60% of the tendon thickness). What is the recommended surgical management?

Explanation

Partial articular-sided supraspinatus tendon avulsion (PASTA) lesions that involve more than 50% of the tendon footprint are typically treated with completion of the tear and formal repair or an in-situ repair to restore mechanics.

Question 41

A 45-year-old manual laborer presents with chronic shoulder weakness. MRI demonstrates a massive, retracted supraspinatus and infraspinatus tear with Goutallier grade 4 fatty infiltration. The subscapularis and teres minor are intact, and there is no glenohumeral arthritis. Which of the following is the most appropriate surgical option?

Explanation

In a young, active patient with an irreparable posterosuperior rotator cuff tear, an intact subscapularis, and no glenohumeral arthritis, a lower trapezius or latissimus dorsi tendon transfer is the most appropriate biological salvage procedure.

Question 42

A 22-year-old rugby player has recurrent anterior shoulder instability. CT scan indicates 28% anterior glenoid bone loss.

What is the most appropriate management?

Explanation

Critical anterior glenoid bone loss (>20-25%) in a contact athlete is best treated with a bony augmentation procedure, most commonly the Latarjet procedure. Arthroscopic soft-tissue stabilization alone in this setting has an unacceptably high recurrence rate.

Question 43

A 65-year-old female undergoes open reduction and internal fixation of a 3-part proximal humerus fracture. Six weeks postoperatively, radiographs show varus collapse of the humeral head and superior screw cutout. Which of the following intraoperative factors most likely contributed to this complication?

Explanation

Failure to restore the medial column (calcar) support in proximal humerus fractures is the most significant biomechanical risk factor for postoperative varus collapse and subsequent screw cutout.

Question 44

A 74-year-old man presents with pseudoparalysis of the right shoulder and severe glenohumeral osteoarthritis.

Which of the following biomechanical changes is achieved by the most appropriate surgical treatment for this condition?

Explanation

The patient has cuff tear arthropathy, which is best treated with a reverse total shoulder arthroplasty (RTSA). RTSA medializes and inferiorizes the center of rotation, thereby increasing the deltoid moment arm and tension.

Question 45

A 35-year-old man presents with a locked posterior shoulder dislocation after a seizure. CT scan confirms a reverse Hill-Sachs lesion involving 25% of the anterior articular surface. What is the most appropriate surgical treatment?

Explanation

For a reverse Hill-Sachs lesion involving 20-40% of the articular surface, transfer of the lesser tuberosity and subscapularis into the defect (modified McLaughlin) is indicated to prevent engagement and recurrent posterior instability.

Question 46

A 42-year-old recreational tennis player has persistent anterior shoulder pain. MRI shows a Type II SLAP tear. After 6 months of failed physical therapy, surgery is planned. Compared to SLAP repair, primary biceps tenodesis in this demographic is associated with:

Explanation

In older patients (>35-40 years) and recreational overhead athletes, primary biceps tenodesis provides superior clinical outcomes, lower revision rates, and better patient satisfaction compared to SLAP repair.

Question 47

A 28-year-old woman presents with isolated lateral scapular winging that worsens when she abducts her arm against resistance. She had a cervical lymph node biopsy 3 months ago. What is the most appropriate initial management?

Explanation

The presentation is consistent with a spinal accessory nerve injury (trapezius palsy causing lateral winging) following a neck biopsy. Initial management for presumed neuropraxic injuries is observation and physical therapy to maintain ROM for up to 1 year.

Question 48

A 62-year-old male presents with weakness in internal rotation. On physical exam, he is instructed to place his hand on his contralateral shoulder and resist the examiner's attempt to pull the hand away. Which specific structure is being isolated and tested?

Explanation

This describes the Bear Hug test, which is highly sensitive and specific for isolating lesions of the upper portion of the subscapularis tendon. The Lift-off test primarily isolates the lower portion.

Question 49

A 30-year-old male cyclist falls directly on his shoulder. Radiographs reveal a Type V acromioclavicular (AC) joint injury. Which of the following accurately describes the pathologic anatomy of this injury pattern?

Explanation

A Type V AC joint injury involves complete disruption of both the AC and CC ligaments along with the deltotrapezial fascia, resulting in >100% (and up to 300%) superior displacement of the clavicle relative to the acromion.

Question 50

Which of the following is the most significant combination of risk factors for nonunion in a midshaft clavicle fracture treated nonoperatively?

Explanation

Complete displacement (especially lacking cortical contact) and significant shortening (>2 cm) are the most significant risk factors for nonunion and poor functional outcomes in nonoperatively managed midshaft clavicle fractures.

Question 51

During an arthroscopic rotator cuff repair, the surgeon evaluates the long head of the biceps tendon for instability. Which of the following structures forms the primary medial restraint to medial subluxation of the biceps tendon within the bicipital groove?

Explanation

The primary medial restraints to the long head of the biceps tendon are the superior glenohumeral ligament (SGHL) and the coracohumeral ligament (CHL), which together form a reflection pulley sling around the tendon.

Question 52

A 45-year-old man presents with anterior shoulder pain and weakness after a fall with his arm externally rotated. He has a positive bear-hug test and increased passive external rotation compared to the contralateral side. What is the most likely diagnosis?

Explanation

The bear-hug and belly-press tests specifically evaluate the subscapularis. Increased passive external rotation also indicates loss of the anterior restraint normally provided by the subscapularis tendon.

Question 53

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

Explanation

Anterior glenoid bone loss greater than 20-25% is a contraindication to isolated soft-tissue repair. A bony augmentation procedure like the Latarjet is required to adequately restore stability.

Question 54

A 35-year-old man presents to the ER after a generalized seizure. His arm is locked in internal rotation. Radiographs show a "lightbulb" sign on the AP view. What is the most common associated bony defect?

Explanation

Seizures commonly cause posterior shoulder dislocations, characterized by locked internal rotation and a "lightbulb" appearance of the humeral head. The associated impaction fracture on the anteromedial humeral head is a reverse Hill-Sachs lesion.

Question 55

A 72-year-old man presents with pseudoparalysis of the shoulder and chronic massive, irreparable tears of the supraspinatus and infraspinatus. His teres minor and subscapularis are intact. Radiographs show severe glenohumeral osteoarthritis with superior migration of the humeral head. What is the treatment of choice?

Explanation

Reverse total shoulder arthroplasty (RTSA) is the treatment of choice for rotator cuff arthropathy with pseudoparalysis. It medializes and distalizes the center of rotation, allowing the deltoid to effectively elevate the arm.

Question 56

According to the Neer classification for proximal humerus fractures, what defines a "part" as being displaced?

Explanation

The Neer classification defines a displaced segment (or "part") as having greater than 1 cm of displacement or greater than 45 degrees of angulation. Fractures that do not meet these criteria are considered 1-part fractures regardless of the number of fracture lines.

Question 57

A 28-year-old tennis player complains of shoulder weakness. On examination, there is lateral winging of the scapula, especially with attempted shoulder abduction. Which nerve is most likely injured?

Explanation

Lateral winging of the scapula is caused by trapezius dysfunction, which is innervated by the spinal accessory nerve (CN XI). Medial winging is caused by serratus anterior dysfunction, innervated by the long thoracic nerve.

Question 58

During an arthroscopic evaluation of a 25-year-old with recurrent anterior shoulder instability, the surgeon notes avulsion of the inferior glenohumeral ligament from the anatomic neck of the humerus.

What is this lesion called?

Explanation

A HAGL (Humeral Avulsion of the Glenohumeral Ligament) lesion occurs when the capsule and IGHL are avulsed from the humeral neck. This causes instability without a traditional Bankart lesion and must be specifically addressed during surgery.

Question 59

A 32-year-old volleyball player presents with insidious onset of posterior shoulder pain and profound isolated weakness in external rotation. Atrophy is noted in the infraspinatus fossa, while the supraspinatus fossa is normal. Where is the most likely site of nerve entrapment?

Explanation

The suprascapular nerve innervates the supraspinatus before passing through the spinoglenoid notch to innervate the infraspinatus. Compression at the spinoglenoid notch (often by a paralabral cyst) causes isolated infraspinatus weakness and atrophy.

Question 60

A 65-year-old woman undergoes open reduction and internal fixation (ORIF) with a locked plate for a 3-part proximal humerus fracture. One year postoperatively, she complains of severe, grinding shoulder pain. Radiographs demonstrate intra-articular screw penetration. What was the most likely intraoperative technical error?

Explanation

Intra-articular screw penetration is the most common complication of locked plating for proximal humerus fractures. It frequently results from postoperative varus collapse of the humeral head, which drives the fixed-angle screws through the articular surface.

Question 61

A 21-year-old cyclist falls directly onto his shoulder. Radiographs show a midshaft clavicle fracture. Which of the following is considered an absolute indication for operative fixation?

Explanation

Absolute indications for operative fixation of a clavicle fracture include open fractures, neurovascular compromise, and severe skin tenting with impending compromise. Shortening and displacement are relative indications.

Question 62

The rotator interval is a triangular space in the anterosuperior shoulder. Which of the following structures is anatomically located within the rotator interval?

Explanation

The rotator interval contains the coracohumeral ligament, the superior glenohumeral ligament (SGHL), the long head of the biceps tendon, and the joint capsule. It is bordered by the supraspinatus superiorly and subscapularis inferiorly.

Question 63

A 26-year-old patient with recurrent anterior shoulder dislocations is found to have an "engaging" Hill-Sachs lesion during diagnostic arthroscopy. Which of the following procedures is most appropriate to combine with an arthroscopic Bankart repair?

Explanation

An engaging Hill-Sachs lesion leverages against the anterior glenoid rim during abduction and external rotation. An arthroscopic Remplissage (tenodesis of the infraspinatus into the defect) converts it to an extra-articular defect, preventing engagement.

Question 64

A 22-year-old elite baseball pitcher presents with posterior shoulder pain during the late cocking phase of throwing. He has a positive Jobe relocation test and glenohumeral internal rotation deficit (GIRD).

What is the primary pathophysiologic mechanism?

Explanation

Internal impingement occurs in overhead athletes during maximum external rotation and abduction. The undersurface of the posterosuperior rotator cuff gets pinched between the greater tuberosity and the posterosuperior glenoid labrum.

Question 65

A 30-year-old bodybuilder feels a sudden pop and pain in his anterior shoulder while performing a heavy bench press. Examination shows loss of the anterior axillary fold and weakness in internal rotation. MRI confirms a rupture of the pectoralis major at its humeral insertion. What is the recommended treatment?

Explanation

Early surgical repair is recommended for complete pectoralis major tears at the humeral insertion in young, active patients or athletes. It predictably restores optimal strength and the cosmetic contour of the axillary fold.

Question 66

Which type of Superior Labrum Anterior to Posterior (SLAP) tear is characterized by a bucket-handle tear of the superior labrum with the biceps anchor remaining solidly attached to the glenoid?

Explanation

A Type III SLAP tear is a bucket-handle tear of the superior labrum with an intact biceps anchor. Type II involves detachment of the superior labrum and biceps anchor, while Type IV is a bucket-handle tear that extends into the biceps tendon.

Question 67

A 75-year-old female presents with chronic right shoulder pain, inability to actively elevate her arm past 40 degrees, and normal passive range of motion. Radiographs demonstrate severe glenohumeral osteoarthritis with superior migration of the humeral head articulating with the acromion. Which of the following is the most appropriate definitive surgical management?

Explanation

Reverse total shoulder arthroplasty is the gold standard for rotator cuff tear arthropathy with pseudoparalysis. It medializes and distalizes the center of rotation, allowing the deltoid to effectively elevate the arm.

Question 68

A 20-year-old male collegiate rugby player presents with recurrent anterior shoulder instability. A 3D CT scan reveals 28% anterior glenoid bone loss. Which of the following procedures provides the most reliable long-term stability for this patient?

Explanation

The open Latarjet procedure (coracoid transfer) is indicated for recurrent anterior instability in high-demand collision athletes with critical anterior glenoid bone loss (typically >20-25%). It provides stability via a triple-blocking effect (bone block, sling effect of the conjoined tendon, and capsular repair).

Question 69

A 68-year-old female sustains a comminuted 4-part proximal humerus fracture after a ground-level fall. She has poor bone quality and severe comminution of the tuberosities.

Which of the following treatments provides the most predictable improvement in forward elevation?

Explanation

Reverse total shoulder arthroplasty provides more predictable functional outcomes in elderly patients with complex 4-part fractures and poor bone quality, as it relies less on tuberosity healing for overhead function compared to hemiarthroplasty or ORIF.

Question 70

A 35-year-old male presents to the emergency department with his arm locked in internal rotation following a generalized tonic-clonic seizure. An axillary radiograph confirms a posterior shoulder dislocation with an impaction fracture of the anteromedial humeral head involving 35% of the articular surface. What is the most appropriate surgical treatment?

Explanation

A reverse Hill-Sachs lesion involving 20-45% of the articular surface is optimally managed with a modified McLaughlin procedure, which involves transferring the lesser tuberosity or subscapularis into the defect to prevent engagement.

Question 71

A 45-year-old manual laborer presents with a massive, irreparable posterosuperior rotator cuff tear. He has an intact subscapularis, preserved glenohumeral cartilage, and profound weakness in external rotation. Which of the following tendon transfers is most appropriate to restore external rotation?

Explanation

Lower trapezius transfer (often with an Achilles allograft) is ideal for young, active patients with an isolated irreparable posterosuperior cuff tear to restore external rotation. Its line of pull closely matches the native infraspinatus.

Question 72

Which of the following glenoid morphologies (Walch classification) in the setting of primary osteoarthritis is characterized by a biconcave surface and posterior subluxation of the humeral head, and carries the highest risk of early glenoid component loosening in anatomic total shoulder arthroplasty?

Explanation

The Walch B2 glenoid is characterized by a biconcave articular surface and posterior subluxation of the humeral head. Uncorrected posterior retroversion leads to eccentric loading and early failure of the glenoid component in anatomic TSA.

Question 73

A 26-year-old male presents with recurrent anterior shoulder instability. An MRI arthrogram reveals an intact anterior labrum but a complete avulsion of the inferior glenohumeral ligament from its humeral attachment, presenting as a 'J-sign'. What is the most likely diagnosis?

Explanation

Humeral Avulsion of the Glenohumeral Ligament (HAGL) presents with a pathognomonic 'J-sign' on MRI. It is an important cause of recurrent anterior instability in patients without a classic Bankart lesion.

Question 74

A 28-year-old professional baseball pitcher complains of posterior shoulder pain during the late cocking phase of throwing. Examination reveals a 25-degree Glenohumeral Internal Rotation Deficit (GIRD) compared to the contralateral side. This condition is primarily driven by contracture of which of the following structures?

Explanation

GIRD in overhead throwing athletes is primarily caused by repetitive microtrauma that leads to contracture and thickening of the posteroinferior capsule.

Question 75

A 32-year-old elite volleyball player presents with painless weakness in external rotation of her dominant shoulder. Examination reveals isolated atrophy of the infraspinatus fossa. The supraspinatus exhibits normal strength. Entrapment of the suprascapular nerve at which of the following locations best explains these findings?

Explanation

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

Question 76

A 30-year-old competitive weightlifter felt a sudden "pop" in his anterior shoulder while performing a heavy bench press. He now has significant ecchymosis on his proximal arm and loss of the anterior axillary fold contour. The vast majority of these injuries occur at which anatomic location?

Explanation

Pectoralis major ruptures in weightlifters almost exclusively occur at or near the humeral insertion. Early surgical repair yields the best return of strength and cosmesis in active patients.

Question 77

A 40-year-old male sustains a distal third clavicle fracture. Radiographs confirm a Neer Type II fracture with superior displacement of the medial fragment.

What is the most appropriate management and primary rationale?

Explanation

Neer Type II distal clavicle fractures involve detachment of the coracoclavicular ligaments from the medial fragment, leading to significant instability and a high nonunion rate (up to 30%) with conservative management, making ORIF the standard of care.

Question 78

A 45-year-old female underwent a lymph node biopsy in the posterior triangle of her neck 3 weeks ago. She now complains of a severe ache in her shoulder and difficulty lifting her arm overhead. Physical examination reveals lateral winging of the scapula. Which nerve was most likely injured?

Explanation

The spinal accessory nerve innervates the trapezius and is vulnerable during procedures in the posterior cervical triangle. Its injury causes lateral scapular winging, whereas long thoracic nerve injury causes medial winging.

Question 79

A 25-year-old male sustains a closed midshaft humerus fracture after a fall. Upon presentation, he has a wrist drop and inability to extend his fingers, but normal sensation in the axillary nerve distribution. Radiographs show acceptable alignment. What is the most appropriate initial management of the nerve injury?

Explanation

Immediate radial nerve palsy in a closed humeral shaft fracture is typically a neuropraxia with a spontaneous recovery rate of over 70-90%. Initial management consists of functional bracing/splinting and observation for 3-4 months before considering exploration.

Question 80

A 55-year-old male falls forward on his outstretched arm. He presents with shoulder pain, a positive lift-off test, and a positive bear-hug test. Passive external rotation is increased compared to the contralateral side. Which structure is most likely injured?

Explanation

A subscapularis tear presents with weakness in internal rotation (positive lift-off, belly-press, or bear-hug tests) and increased passive external rotation due to the loss of the anterior dynamic restraint.

Question 81

A 50-year-old female with poorly controlled type II diabetes presents with an insidious onset of severe diffuse shoulder pain and a profound loss of both active and passive motion, particularly external rotation. Radiographs are normal. What is the most likely diagnosis?

Explanation

Adhesive capsulitis (frozen shoulder) classically presents with a painful, global loss of both active and passive range of motion, with normal radiographs. Diabetes mellitus is a major risk factor for this condition.

Question 82

A 24-year-old male with recurrent anterior shoulder instability undergoes arthroscopy. He is found to have an anterior Bankart lesion and a large Hill-Sachs defect that engages the anterior glenoid rim during abduction and external rotation. Glenoid bone loss is estimated at 10%. Which of the following is the most appropriate surgical treatment?

Explanation

An engaging Hill-Sachs lesion in the setting of subcritical (<20%) glenoid bone loss is effectively treated with a Remplissage (tenodesis of the infraspinatus into the defect) combined with an anterior Bankart repair to make the defect extra-articular.

Question 83

A 22-year-old collegiate baseball pitcher is diagnosed with a Type II SLAP tear after failing nonoperative management. What is the primary biomechanical mechanism responsible for this specific labral pathology in overhead throwers?

Explanation

The 'peel-back' mechanism occurs during the late cocking phase of throwing (extreme abduction and external rotation), placing significant torsional stress on the biceps root and causing Type II SLAP tears in overhead athletes.

Question 84

A 70-year-old female presents 1 year after an anatomic total shoulder arthroplasty performed for a complex proximal humerus fracture. She is unable to actively elevate her arm above 60 degrees. Radiographs show superior migration of the humeral head and resorption of the greater tuberosity. What is the primary cause of her functional deficit?

Explanation

Greater tuberosity nonunion or resorption is a major complication of anatomic shoulder arthroplasty for fracture. It results in loss of posterosuperior rotator cuff function, leading to superior head migration and pseudoparalysis.

Question 85

A 22-year-old competitive rugby player presents with recurrent anterior shoulder instability. A 3D computed tomography (CT) scan reveals 26% anterior glenoid bone loss. Which of the following is the most appropriate surgical intervention to minimize the risk of recurrent instability?

Explanation

In young collision athletes with critical anterior glenoid bone loss (typically >20-25%), soft tissue repairs like an arthroscopic Bankart have unacceptably high failure rates. The open Latarjet procedure addresses this critical bone loss by transferring the coracoid process, providing a triple-blocking effect.

Question 86

A 45-year-old heavy laborer presents with a massive, irreparable posterosuperior rotator cuff tear. He has intact subscapularis function, active forward elevation to 130 degrees, but a severe lag sign in external rotation. Radiographs show no glenohumeral osteoarthritis. What is the most appropriate surgical management?

Explanation

Latissimus dorsi or lower trapezius tendon transfers are indicated for young, active patients with massive, irreparable posterosuperior rotator cuff tears and intact subscapularis function without arthropathy. Pectoralis major transfers are reserved for irreparable subscapularis tears, while reverse shoulder arthroplasty is preferred for older patients or those with pseudoparalysis and arthritis.

Question 87

A 78-year-old female with osteoporosis sustains a highly comminuted 4-part proximal humerus fracture with a split humeral head.

What is the most appropriate surgical management to maximize her functional outcome?

Explanation

In elderly patients with complex 4-part fractures or head-splitting variants, reverse total shoulder arthroplasty (RTSA) provides more predictable pain relief and functional restoration than ORIF or hemiarthroplasty. RTSA relies on the deltoid rather than the often unpredictable healing of osteoporotic tuberosities.

Question 88

A 30-year-old professional volleyball player complains of vague posterior shoulder pain and isolated weakness in external rotation. An MRI reveals a paralabral cyst at the spinoglenoid notch. This finding is most commonly associated with which of the following concomitant pathologies?

Explanation

Paralabral cysts at the spinoglenoid notch compress the suprascapular nerve distal to its innervation of the supraspinatus, causing isolated infraspinatus weakness. These cysts act as a one-way valve and are highly associated with posterior or posterosuperior labral tears.

Question 89

A 25-year-old male presents with recurrent anterior shoulder dislocations. Imaging demonstrates an off-track engaging Hill-Sachs lesion with 12% anterior glenoid bone loss. Which of the following is the most appropriate arthroscopic surgical management?

Explanation

For subcritical glenoid bone loss (<20%) combined with an engaging, off-track Hill-Sachs lesion, an arthroscopic Bankart repair supplemented with a remplissage (infraspinatus tenodesis into the defect) is highly effective. Remplissage converts an intra-articular defect to extra-articular, preventing engagement over the anterior glenoid rim.

Question 90

Which of the following clinical scenarios represents an absolute indication for immediate operative fixation of an acute midshaft clavicle fracture?

Explanation

While complete displacement, shortening, and athletic status may be relative indications for ORIF of the clavicle, an open fracture is an absolute indication for surgical management. Other absolute indications include polytrauma requiring early weight-bearing through the upper extremities and progressive neurologic deficit.

Question 91

A 55-year-old man presents with anterior shoulder pain and weakness with internal rotation. On examination, the examiner elevates the patient's arm to 90 degrees in the scapular plane, flexes the elbow to 90 degrees, and asks the patient to internally rotate against resistance. The patient is unable to maintain the hand against his opposite shoulder. Which structure is most likely injured?

Explanation

The clinical examination describes the "Bear Hug" test, which is highly sensitive for subscapularis tendon pathology. An inability to maintain the internally rotated hand against the chest or opposite shoulder indicates a subscapularis tear.

Question 92

A 45-year-old manual laborer undergoes shoulder arthroscopy for superior shoulder pain. A Type II SLAP tear is identified with no other intra-articular pathology. Based on current literature, what is the best surgical management for this patient to minimize postoperative stiffness and reoperation?

Explanation

In patients over age 40 or those who perform heavy manual labor, primary SLAP repair has a higher rate of stiffness, continued pain, and revision compared to biceps tenodesis. Biceps tenodesis effectively eliminates the pain generator while preserving functional strength.

Question 93

A 65-year-old male undergoes open reduction and internal fixation (ORIF) with a locking plate for a 3-part proximal humerus fracture. Six weeks postoperatively, radiographs demonstrate intra-articular screw penetration. What is the most common technical error during the index procedure leading to this complication?

Explanation

Intra-articular screw penetration after proximal humerus locking plate fixation is most commonly a secondary complication due to varus collapse of the humeral head. This collapse is almost exclusively caused by a failure to reconstruct or support the medial calcar during the initial reduction.

Question 94

A 35-year-old male sustains a severe seizure resulting in a locked posterior shoulder dislocation. CT imaging reveals a reverse Hill-Sachs lesion involving 25% of the anteromedial humeral head articular surface. What is the most appropriate management?

Explanation

For reverse Hill-Sachs lesions involving 20% to 40% of the articular surface, a modified McLaughlin procedure (transfer of the lesser tuberosity and subscapularis into the defect) is indicated to restore joint stability. Defects larger than 40% typically require structural allografting or arthroplasty.

Question 95

Which of the following preoperative factors has been most strongly correlated with structural failure (non-healing) following arthroscopic repair of a large rotator cuff tear?

Explanation

Advanced fatty infiltration (Goutallier grade 3 or 4) and significant muscle atrophy are the strongest independent predictors of structural failure and poor functional outcomes following rotator cuff repair. These degenerative muscle changes are largely irreversible even after successful tendon-to-bone healing.

Question 96

A 40-year-old male sustains a high-energy trauma resulting in a severely displaced scapular fracture. Which of the following parameters is a widely accepted indication for operative fixation of a scapular neck/body fracture?

Explanation

Operative indications for scapula fractures include significant intra-articular glenoid displacement (step-off > 4-5 mm), profound medialization of the glenohumeral joint (usually >20 mm), or severe angular deformity (>40 degrees). Minor angulation and small displacements are reliably treated non-operatively.

Question 97

During an open Latarjet procedure, aggressive medial retraction of the conjoint tendon places a specific nerve at risk of traction injury. Which nerve is most vulnerable, and what is its expected distance from the tip of the coracoid?

Explanation

The musculocutaneous nerve penetrates the deep surface of the coracobrachialis approximately 3 to 8 cm distal to the tip of the coracoid. Overzealous medial or distal retraction of the conjoint tendon during a Latarjet procedure can cause a traction neurapraxia to this nerve.

Question 98

During an arthroscopic rotator cuff repair, the surgeon identifies the 'comma sign' tissue dropping deep into the joint. Tracing this structure superiorly and laterally leads directly to the torn edge of which anatomical structure?

Explanation

The 'comma sign' is formed by the avulsion and medial retraction of the superior glenohumeral ligament and coracohumeral ligament complex. Following the comma sign superiorly and laterally leads directly to the superolateral corner of a retracted subscapularis tear.

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

AAOS Shoulder MCQs (Set 4): Rotator Cuff, Instability & Fractures | Board Review

Key Takeaway

AAOS Shoulder MCQs (Set 4): Rotator Cuff, Instability & Fractures | Board Review

Chapter Index