ABOS Shoulder MCQs (Set 3): Rotator Cuff & Instability Qs

Question 1

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

Shoulder 2002 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 2002 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 2002 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 2002 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 2002 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 2002 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 2002 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 2002 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 2002 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 2002 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 2002 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 74-year-old woman presents with severe shoulder pain and an inability to actively elevate her right arm above 45 degrees. Passive forward flexion is 160 degrees. Radiographs demonstrate superior migration of the humeral head with articulation against the acromion, forming an "acetabularized" coracoacromial arch, and severe glenohumeral osteoarthritis (Hamada Grade 3). Which of the following is the most appropriate surgical treatment?

Explanation

Reverse total shoulder arthroplasty is the gold standard for rotator cuff tear arthropathy with pseudoparalysis. Anatomic total shoulder arthroplasty is contraindicated due to the deficient rotator cuff, which would lead to superior escape and early glenoid loosening.

Question 27

A 21-year-old collegiate rugby player sustains a fourth anterior shoulder dislocation. A 3D CT scan reveals 25% anterior glenoid bone loss with an engaging Hill-Sachs lesion. Which of the following surgical procedures is most appropriate to minimize the risk of recurrent instability?

Explanation

The Latarjet procedure is indicated for patients with critical anterior glenoid bone loss (typically >20-25%), especially in high-demand contact athletes. Soft tissue procedures alone, such as an arthroscopic Bankart repair, have an unacceptably high failure rate in the setting of significant bone loss.

Question 28

A 55-year-old man presents with persistent shoulder pain and profound weakness 3 weeks after an acute, first-time anterior glenohumeral dislocation. The dislocation was reduced in the emergency department, and radiographs confirm a concentric joint. Which of the following is the most common associated injury responsible for his current symptoms?

Explanation

In patients older than 40 years of age, the incidence of a concomitant rotator cuff tear with a first-time anterior dislocation is extremely high (up to 30-80%). Persistent pain and weakness after reduction in this age group should prompt an MRI to evaluate the rotator cuff.

Question 29

A 35-year-old man presents with a locked posterior shoulder dislocation after a generalized seizure. CT scan reveals an anterior articular impaction fracture (reverse Hill-Sachs lesion) involving 35% of the humeral head articular surface. Which of the following is the most appropriate treatment?

Explanation

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

Question 30

A 24-year-old minor league baseball pitcher presents with posterior shoulder pain during the late-cocking phase of throwing. Examination reveals a 25-degree loss of internal rotation compared to the contralateral side, with intact overall arc of motion. What is the most appropriate initial management?

Explanation

This presentation is consistent with Glenohumeral Internal Rotation Deficit (GIRD), commonly seen in throwers due to posterior capsular contracture. The first-line treatment is a targeted stretching program (sleeper stretches) to restore internal rotation.

Question 31

A 29-year-old male weightlifter complains of vague posterior shoulder pain and selective weakness in external rotation. An MRI reveals an isolated paralabral cyst at the spinoglenoid notch with associated muscle edema. The cyst most likely originated from which of the following?

Explanation

Paralabral cysts at the spinoglenoid notch cause isolated suprascapular nerve compression affecting only the infraspinatus (weakness in external rotation). These cysts are highly associated with adjacent posterior labral tears.

Question 32

A 48-year-old man falls on an outstretched arm and is diagnosed with an isolated, complete rupture of the subscapularis tendon. Which of the following physical examination findings is most specific for this injury?

Explanation

The bear-hug test, along with the belly-press and lift-off tests, specifically evaluates the integrity of the subscapularis. Hornblower's sign evaluates the teres minor, while Jobe's test evaluates the supraspinatus.

Question 33

When evaluating a patient with a massive rotator cuff tear for a potential surgical repair, which of the following preoperative MRI findings is the strongest predictor of structural failure after repair?

Explanation

Advanced fatty infiltration (Goutallier grade 3 or 4) indicates irreversible muscle atrophy and is the strongest predictor of clinical and structural failure following rotator cuff repair. Acromiohumeral intervals less than 7 mm also portend a poor prognosis.

Question 34

In the management of recurrent anterior shoulder instability, the "track" concept is used to evaluate interacting bone loss. An arthroscopic Bankart repair combined with an arthroscopic Remplissage is most appropriately indicated for which of the following scenarios?

Explanation

An arthroscopic Remplissage (infraspinatus tenodesis into the defect) with Bankart repair is indicated for subcritical glenoid bone loss (<20%) combined with an off-track (engaging) Hill-Sachs lesion. Critical glenoid bone loss (>20-25%) requires a bone-block procedure like Latarjet.

Question 35

A 32-year-old male bodybuilder feels a sudden "pop" and tearing sensation in his anterior axilla while performing a heavy bench press. Examination reveals loss of the anterior axillary fold. During the bench press motion, which portion of the injured muscle typically ruptures first?

Explanation

Pectoralis major ruptures typically occur at the humeral insertion during eccentric loading (e.g., bench press). The sternal head is under maximum tension when the arm is extended and externally rotated at the bottom of the lift, making it the first to fail.

Question 36

A 16-year-old female gymnast complains of bilateral shoulder pain and a feeling of the shoulders "sliding out of joint." Examination shows a sulcus sign of 2+ bilaterally, hyperlaxity of the elbows and knees, and positive apprehension tests without a distinct history of trauma. What is the most appropriate initial management?

Explanation

Multidirectional instability (MDI) typically presents with generalized laxity and atraumatic instability. The mainstay of initial treatment is a prolonged course (minimum 6 months) of physical therapy focusing on rotator cuff strengthening and periscapular stabilizers.

Question 37

A 28-year-old man undergoes an MRI arthrogram for recurrent anterior shoulder instability. The radiologist notes a "J-sign" on the coronal sequences, representing extravasation of contrast into the axillary recess. This imaging finding is pathognomonic for which of the following lesions?

Explanation

The normal inferior glenohumeral ligament creates a U-shaped axillary pouch on MRI arthrogram. A humeral avulsion of the glenohumeral ligament (HAGL lesion) disrupts this pouch, causing contrast to leak inferiorly and forming a pathognomonic J-shape.

Question 38

The Latarjet procedure provides stability to the anterior shoulder through a "triple blocking" effect. While the osseous block provides static resistance, the dynamic sling effect in abduction and external rotation is provided by which of the following structures?

Explanation

The Latarjet "triple block" consists of: 1) the bone block increasing the glenoid arc, 2) the dynamic sling effect of the conjoint tendon (short head of biceps and coracobrachialis) tensioning the inferior subscapularis, and 3) the capsule repair to the coracoacromial ligament.

Question 39

A 45-year-old manual laborer presents with superior shoulder pain and positive O'Brien and Speed's tests. MRI reveals an isolated Type II SLAP tear. Nonoperative management has failed. Based on current literature, which of the following surgical options offers the most reliable clinical outcome and highest rate of return to work for this patient?

Explanation

In patients over 40 years old, particularly manual laborers, primary biceps tenodesis has been shown to yield more reliable pain relief and a higher rate of return to previous activity levels compared to arthroscopic SLAP repair, which has a higher complication and stiffness rate in this demographic.

Question 40

A 42-year-old tennis player undergoes diagnostic shoulder arthroscopy for persistent pain. The surgeon visualizes a fraying and tearing of the supraspinatus tendon from the articular side. This specific lesion is commonly referred to by which of the following acronyms?

Explanation

A PASTA lesion stands for Partial Articular-Sided Tendon Avulsion, typically involving the supraspinatus footprint. If the tear involves >50% of the tendon thickness, completion and repair or a transtendon repair is generally indicated.

Question 41

According to the suspension bridge biomechanical model of the rotator cuff proposed by Burkhart, stress is effectively transmitted across the crescent area of the supraspinatus and infraspinatus insertions by a thickened band of capsular tissue. What is this structure called?

Explanation

The rotator cable is a thickened band of tissue that spans from the coracohumeral ligament to the infraspinatus. It acts like a suspension bridge to stress-shield the thinner avascular crescent area of the rotator cuff insertion.

Question 42

A 33-year-old man presents with vague posterior shoulder pain and numbness over the lateral deltoid after a blunt trauma to the posterior shoulder. An MRI reveals an isolated fluid collection in the quadrilateral space. Which nerve is most likely compressed in this space?

Explanation

The quadrilateral space contains the axillary nerve and the posterior circumflex humeral artery. Compression here (Quadrilateral Space Syndrome) leads to deltoid weakness and paresthesias over the lateral shoulder.

Question 43

Which of the following is considered the most accurate and reliable imaging method for preoperative quantification of glenoid bone loss in a patient with recurrent anterior shoulder instability?

Explanation

A 3D CT scan with digital subtraction of the humeral head to provide an en face view of the glenoid is the gold standard. The best-fit circle method is used over the inferior portion of the glenoid to quantify the percentage of anterior bone loss.

Question 44

During an open approach for a massive rotator cuff tear, the surgeon must mobilize the supraspinatus and infraspinatus tendons. Excessive medial traction can cause a stretch injury to the suprascapular nerve. Which of the following accurately describes the anatomic path of this nerve?

Explanation

The suprascapular nerve passes through the suprascapular notch inferior to the transverse scapular ligament, and then through the spinoglenoid notch inferior to the spinoglenoid ligament. The suprascapular artery travels superior to the transverse scapular ligament ("Army over, Navy under").

Question 45

An 80-year-old woman with a massive, irreparable rotator cuff tear presents with disabling pain and "anterosuperior escape" of the humeral head upon attempted active forward elevation. The loss of which structure is the primary anatomical prerequisite for anterosuperior escape to occur?

Explanation

Anterosuperior escape occurs when the restraining mechanism of the coracoacromial (CA) arch is lost, typically due to prior acromioplasty or CA ligament resection in the presence of a massive, irreparable cuff tear. The CA ligament is critical for preventing superior translation in cuff-deficient shoulders.

Question 46

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

Explanation

The Latarjet procedure is indicated for patients with critical anterior glenoid bone loss (typically >20-25%), especially in collision athletes. Arthroscopic soft-tissue repair alone has unacceptably high failure rates in this setting.

Question 47

A 55-year-old man presents with anterior shoulder pain and weakness after a fall. On examination, he demonstrates a positive bear-hug test and a positive belly-press test, but normal external rotation strength. Which tendon is most likely injured?

Explanation

The bear-hug and belly-press tests specifically evaluate the subscapularis tendon. The belly-press test assesses the lower subscapularis, while the bear-hug test evaluates the upper subscapularis.

Question 48

Based on the glenoid track concept, which of the following defines an 'off-track' Hill-Sachs lesion?

Explanation

An 'off-track' Hill-Sachs lesion has a medial margin that extends beyond the calculated glenoid track. This allows the lesion to engage the anterior glenoid rim during extreme abduction and external rotation, causing recurrent instability.

Question 49

A 35-year-old man is evaluated in the emergency department following an unprovoked generalized tonic-clonic seizure. His arm is locked in internal rotation and he cannot actively externally rotate. Radiographs reveal a posterior shoulder dislocation. Which bony defect is most likely present?

Explanation

Posterior shoulder dislocations are classic following seizures or electrical shock and lock the arm in internal rotation. The anteromedial humeral head impacts the posterior glenoid, creating an impaction fracture known as a reverse Hill-Sachs lesion.

Question 50

A 48-year-old manual laborer presents with persistent anterior shoulder pain. MRI arthrogram reveals an isolated Type II SLAP tear. Nonoperative management has failed. What is the most appropriate surgical treatment?

Explanation

In patients over 40 or those who perform heavy labor, biceps tenodesis is preferred over SLAP repair. SLAP repair in older patients has higher complication rates, including postoperative stiffness and persistent pain.

Question 51

A 52-year-old man presents with chronic shoulder pain and pseudoparalysis of elevation. MRI shows a massive, retracted, and fatty-infiltrated supraspinatus and infraspinatus tear, but an intact subscapularis and normal articular cartilage. Which of the following is the most appropriate joint-preserving surgical option?

Explanation

Superior capsular reconstruction (SCR) is indicated for younger patients with massive, irreparable posterosuperior cuff tears and an intact subscapularis who lack advanced glenohumeral arthritis. RTSA is typically reserved for older patients or those with arthropathy.

Question 52

A 72-year-old female presents with severe right shoulder pain, active forward elevation to 40 degrees, and hornblower's sign. Radiographs show superior migration of the humeral head and bone-on-bone glenohumeral arthritis. What is the most appropriate surgical treatment?

Explanation

Reverse total shoulder arthroplasty is the gold standard for rotator cuff tear arthropathy with pseudoparalysis. It medializes and distalizes the center of rotation, optimizing the deltoid's moment arm to allow active elevation.

Question 53

A 25-year-old athlete suffered a traumatic shoulder dislocation. MRI reveals a 'J-sign' on the axial and coronal fluid-sensitive sequences. This finding is pathognomonic for which of the following lesions?

Explanation

A HAGL lesion represents an avulsion of the inferior glenohumeral ligament from its humeral attachment. On an MRI arthrogram, extravasation of contrast into the axillary pouch creates the classic 'J-sign'.

Question 54

A 22-year-old professional baseball pitcher presents with posterior shoulder pain during the late-cocking phase of throwing. MRI shows articular-sided partial tearing of the supraspinatus and posterosuperior labral fraying. Which structure is the rotator cuff abutting to cause this pathology?

Explanation

Internal impingement occurs during extreme abduction and external rotation (late-cocking phase), where the posterosuperior rotator cuff is pinched between the greater tuberosity and the posterosuperior glenoid rim.

Question 55

In the evaluation of anterior shoulder instability, how does an ALPSA (anterior labroligamentous periosteal sleeve avulsion) lesion mechanically differ from a classic Bankart lesion?

Explanation

An ALPSA lesion is characterized by an intact periosteal sleeve that allows the detached anteroinferior labrum to shift medially and inferiorly, healing in a non-anatomic position on the glenoid neck. A classic Bankart involves a frank capsuloperiosteal disruption.

Question 56

During a massive rotator cuff repair, you identify a retracted subscapularis tendon. To safely mobilize it, you must be aware of its primary innervation. The subscapularis is innervated by branches from which cord of the brachial plexus?

Explanation

The subscapularis is innervated by the upper and lower subscapular nerves, which both branch directly from the posterior cord of the brachial plexus.

Question 57

An 18-year-old competitive swimmer presents with multidirectional instability of the shoulder. She has completed 6 months of an aggressive periscapular stabilization and strengthening program without improvement. What is the most appropriate surgical intervention?

Explanation

When a minimum of 6 months of physical therapy fails in a patient with true multidirectional instability (MDI), a capsular shift (typically addressing the redundant inferior capsular pouch) is the surgical treatment of choice.

Question 58

When performing an arthroscopic stabilization for recurrent anterior shoulder instability, which of the following is the primary indication for adding a 'Remplissage' procedure to a Bankart repair?

Explanation

Remplissage involves tenodesis of the infraspinatus and posterior capsule into a Hill-Sachs defect. It is indicated for off-track, engaging Hill-Sachs lesions in the setting of subcritical (<15-20%) anterior glenoid bone loss.

Question 59

Which of the following anatomic structures are the primary components found within the rotator interval?

Explanation

The rotator interval is a triangular space between the supraspinatus and subscapularis. It contains the superior glenohumeral ligament (SGHL), the coracohumeral ligament (CHL), and the long head of the biceps tendon.

Question 60

A lower trapezius tendon transfer is performed for a patient with an irreparable posterosuperior rotator cuff tear. The line of pull of the transferred lower trapezius tendon most closely mimics which native rotator cuff muscle to restore what specific motion?

Explanation

The lower trapezius transfer vector closely mimics the infraspinatus muscle. It is highly effective at restoring active external rotation in patients with irreparable posterosuperior cuff tears.

Question 61

A 40-year-old man presents with vague posterior shoulder pain and isolated atrophy of the teres minor on physical examination. MRI confirms fatty infiltration isolated to the teres minor. Compression of which nerve in the quadrilateral space is the most likely cause?

Explanation

Quadrilateral space syndrome involves compression of the axillary nerve and posterior circumflex humeral artery. It classically presents with isolated teres minor atrophy, although the deltoid can also be affected depending on the exact site of compression.

Question 62

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. What is the most appropriate surgical management?

Explanation

Anterior glenoid bone loss greater than 20-25% in a contact athlete is an indication for a bony augmentation procedure, most commonly the Latarjet procedure. Soft tissue Bankart repairs have an unacceptably high failure rate in this setting.

Question 63

A 68-year-old male with a massive, retracted rotator cuff tear is being evaluated for surgical repair. Preoperative MRI shows Goutallier stage 4 fatty infiltration of the supraspinatus and infraspinatus. What does this finding indicate regarding the prognosis of a primary repair?

Explanation

Goutallier stage 3 or 4 fatty infiltration (more fat than muscle) is an irreversible change that strongly correlates with poor functional outcomes and high re-tear rates following primary rotator cuff repair.

Question 64

A 35-year-old male weightlifter complains of vague posterior shoulder pain and weakness with external rotation. MRI reveals a paralabral cyst located strictly at the spinoglenoid notch. Which physical exam finding is most likely present?

Explanation

A cyst at the spinoglenoid notch compresses the distal suprascapular nerve, resulting in isolated denervation and weakness of the infraspinatus. Compression at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 65

During the Latarjet procedure, the coracoid process is transferred to the anterior glenoid. The primary stabilizing mechanism of this procedure in abduction and external rotation is attributed to:

Explanation

While the Latarjet provides a triple blocking effect, the most significant biomechanical contribution in abduction and external rotation is the dynamic sling effect of the conjoint tendon over the inferior subscapularis.

Question 66

A 28-year-old overhead athlete is diagnosed with recurrent shoulder instability. Advanced imaging demonstrates an 'off-track' Hill-Sachs lesion and 12% anterior glenoid bone loss. Which of the following is the most appropriate surgical treatment?

Explanation

An 'off-track' Hill-Sachs lesion will engage the anterior glenoid rim during external rotation. When combined with subcritical glenoid bone loss (less than 20%), an arthroscopic Bankart repair combined with Remplissage is indicated to prevent engagement.

Question 67

A 72-year-old female presents with chronic shoulder pain, an inability to actively elevate her arm past 45 degrees (pseudoparalysis), and an intact subscapularis. Radiographs show a preserved joint space without glenohumeral arthritis. What is the most reliable surgical option?

Explanation

In elderly patients with massive, irreparable posterosuperior rotator cuff tears and pseudoparalysis, reverse total shoulder arthroplasty provides the most reliable restoration of active elevation, even in the absence of advanced arthritis.

Question 68

A patient with a massive rotator cuff tear is examined in the clinic. The examiner supports the patient's arm in 90 degrees of abduction in the scapular plane with the elbow flexed to 90 degrees, and asks the patient to externally rotate against resistance. The patient is unable to do so, and the hand drops forward. Which muscle is predominantly deficient?

Explanation

This describes Hornblower's sign, which is highly sensitive and specific for an irreparable tear or severe fatty degeneration of the teres minor.

Question 69

Which of the following findings accurately differentiates an Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) lesion from a classic Bankart lesion on MRI?

Explanation

An ALPSA lesion involves an avulsion of the anterior labroligamentous complex where the periosteum remains intact, allowing the labrum to roll medially and scar down on the glenoid neck. It has a higher recurrence rate if not properly mobilized during repair.

Question 70

A 40-year-old male with recurrent anterior shoulder dislocations undergoes an MRI arthrogram. The radiologist notes a 'J-sign' in the axillary pouch. This imaging finding is characteristic of which pathology?

Explanation

A HAGL lesion occurs when the inferior glenohumeral ligament is avulsed from its humeral attachment. On coronal MRI arthrogram, extravasation of contrast through this defect creates a characteristic U-shaped or J-shaped appearance.

Question 71

During a Latarjet procedure, careful retraction is required when exposing the anterior glenoid neck to avoid irogenic nerve injury. Which nerve is most at risk when retracting the conjoint tendon medially?

Explanation

The musculocutaneous nerve typically enters the coracobrachialis 3 to 5 cm distal to the coracoid process. Vigorous medial retraction of the conjoint tendon places this nerve at highest risk of traction injury.

Question 72

A 60-year-old man sustains an acute traumatic fall. He presents with profound weakness in internal rotation and a positive lift-off test. If this specific rotator cuff tendon is completely torn and left untreated, which secondary pathology is most likely to develop?

Explanation

The subscapularis tendon and the coracohumeral ligament are critical stabilizers of the long head of the biceps tendon. An untreated complete subscapularis tear frequently leads to medial subluxation or dislocation of the biceps tendon.

Question 73

A 55-year-old male is evaluated for chronic shoulder pain. Anteroposterior (AP) radiographs reveal an acromiohumeral interval (AHI) of 4 mm. This measurement suggests:

Explanation

A normal AHI is 7 to 14 mm. An AHI of less than 7 mm (such as 4 mm) indicates superior migration of the humeral head, often seen with massive, chronic rotator cuff tears, and correlates with high failure rates for primary repair.

Question 74

A 50-year-old active female is diagnosed with a Partial Articular-sided Supraspinatus Tendon Avulsion (PASTA) lesion. Arthroscopic evaluation estimates the tear involves 60% of the tendon footprint depth. What is the most widely accepted surgical management?

Explanation

For articular-sided partial rotator cuff tears involving greater than 50% of the tendon footprint thickness, the standard of care is to complete the tear and perform a formal full-thickness repair (or an in situ repair).

Question 75

A 35-year-old male suffers a first-time seizure and subsequently complains of shoulder pain and severely restricted external rotation. An axillary radiograph confirms a posterior shoulder dislocation with an anteromedial humeral head defect involving 30% of the articular surface. What is the best surgical intervention?

Explanation

A locked posterior dislocation with a reverse Hill-Sachs defect involving 20% to 40% of the articular surface is best treated with a Modified McLaughlin procedure (transfer of the subscapularis and/or lesser tuberosity into the defect) to prevent recurrent engagement.

Question 76

When performing an arthroscopic Superior Capsular Reconstruction (SCR) for a massive irreparable rotator cuff tear, the graft is anchored to the superior glenoid medially and the greater tuberosity laterally. What primary biomechanical effect does this graft provide?

Explanation

The SCR uses a dermal allograft or fascia lata to statically replace the superior capsule. This depresses the humeral head, preventing superior migration and improving the fulcrum for the intact deltoid to elevate the arm.

Question 77

A 45-year-old construction worker undergoes an arthroscopic double-row rotator cuff repair. Postoperatively, the patient acknowledges smoking 1 pack of cigarettes per day. How does nicotine primarily compromise rotator cuff tendon-to-bone healing?

Explanation

Nicotine is a potent vasoconstrictor that significantly impairs microvascular perfusion at the repair site. This leads to local tissue hypoxia, impaired fibroblast function, and a markedly increased rate of non-healing and re-tearing.

Question 78

A 19-year-old collegiate swimmer presents with bilateral shoulder pain, a sulcus sign of 2 cm, and apprehension in multiple positions. She has failed 6 months of dedicated physical therapy emphasizing periscapular strengthening. What is the surgical treatment of choice for her condition?

Explanation

This patient has multidirectional instability (MDI). When prolonged conservative management fails, the surgical standard of care is a capsular shift (open or arthroscopic capsular plication) to reduce the redundant capsular volume.

Question 79

A 25-year-old baseball pitcher presents with posterior shoulder pain during the late cocking phase of throwing. He demonstrates increased external rotation and decreased internal rotation (GIRD) compared to the contralateral shoulder. MRI reveals a partial articular-sided tear of the infraspinatus and a posterosuperior labral fraying. What is the most likely diagnosis?

Explanation

Internal impingement occurs in overhead athletes during maximum abduction and external rotation. The greater tuberosity abuts the posterosuperior glenoid, causing undersurface 'kissing lesions' of the supraspinatus/infraspinatus and posterosuperior labrum.

Question 80

A massive rotator cuff tear is generally defined by which of the following criteria?

Explanation

The classic definition of a massive rotator cuff tear, originally described by Cofield, is a tear with a diameter greater than 5 cm. Alternatively, Gerber defines it as the complete detachment of two or more rotator cuff tendons.

Question 81

A 52-year-old male presents with anterior shoulder pain characterized by a 'clunking' sensation when moving the arm into forward elevation and internal rotation. MRI reveals a narrowed distance of 4 mm between the coracoid process and the lesser tuberosity. What is the most likely diagnosis?

Explanation

Subcoracoid impingement presents with anterior shoulder pain exacerbated by flexion, adduction, and internal rotation. It is confirmed radiographically or on MRI when the coracohumeral interval is less than 6 mm.

Question 82

A 65-year-old man presents with an inability to actively raise his right arm above 40 degrees, despite having 150 degrees of passive forward elevation. MRI demonstrates a massive, retracted tear of the supraspinatus and infraspinatus with Goutallier grade 4 fatty infiltration. His subscapularis and deltoid are intact. What is the most appropriate surgical treatment?

Explanation

In a patient with true pseudoparalysis and severe fatty infiltration (Goutallier grade 4) of a massive rotator cuff tear, a reverse total shoulder arthroplasty provides the most reliable return of active elevation.

Question 83

During a Latarjet procedure for recurrent anterior shoulder instability, the coracoid process is transferred to the anterior glenoid. Which nerve is most at risk during the distal exposure and mobilization of the conjoined tendon?

Explanation

The musculocutaneous nerve typically enters the coracobrachialis approximately 3 to 8 cm distal to the coracoid tip. It is highly vulnerable to stretch or transection during mobilization and retraction of the conjoined tendon.

Question 84

A 22-year-old collegiate athlete presents with recurrent anterior shoulder dislocations. Imaging demonstrates a bipolar bone loss scenario. Which of the following defines an "engaging" Hill-Sachs lesion?

Explanation

An engaging Hill-Sachs lesion drops over the anterior glenoid rim. Its long axis aligns parallel to the anterior glenoid rim when the arm is placed in a functional position of abduction and external rotation.

Question 85

A 55-year-old woman undergoes arthroscopic repair of a full-thickness supraspinatus tear. Which of the following best describes the normal progression of rotator cuff tendon healing to bone?

Explanation

Rotator cuff healing typically occurs via initial fibrovascular scar formation. This gradually remodels to form a fibrocartilaginous transition zone integrating with the bone via Sharpey fibers, though it rarely fully recreates the native enthesis.

Question 86

A 20-year-old male athlete has failed a previous arthroscopic Bankart repair and presents with recurrent anterior instability. A 3D CT scan reveals 25% anterior glenoid bone loss. What is the most appropriate definitive management?

Explanation

In the setting of failed soft-tissue stabilization and critical anterior glenoid bone loss (>20-25%), a coracoid transfer (Latarjet procedure) is indicated to restore anterior glenoid bone stock and provide a dynamic sling effect.

Question 87

Which physical examination finding is most specific for diagnosing a complete subscapularis tendon rupture?

Explanation

Increased passive external rotation compared to the normal contralateral shoulder, along with positive lift-off or belly-press tests, is a highly specific physical examination finding for a subscapularis tendon rupture.

Question 88

A 45-year-old male weightlifter presents with acute weakness in internal rotation after feeling a "pop" in his shoulder. MRI confirms an acute, isolated, full-thickness subscapularis tear retracted to the glenoid rim. What is the most appropriate management?

Explanation

Acute traumatic full-thickness subscapularis tears in active patients should undergo early surgical repair. Rapid muscle atrophy and fatty infiltration occur much earlier in the subscapularis compared to the supraspinatus.

Question 89

A 68-year-old woman presents with chronic shoulder pain and imaging showing a massive, irreparable posterosuperior rotator cuff tear. She has an intact subscapularis and no pseudoparalysis. Which tendon transfer is most appropriate to restore external rotation?

Explanation

The lower trapezius transfer is indicated for irreparable posterosuperior rotator cuff tears. It has a synergistic line of pull that excellently restores external rotation and centers the humeral head.

Question 90

Which of the following structures constitutes the primary restraint to anterior translation of the humeral head with the arm in 90 degrees of abduction and 90 degrees of external rotation?

Explanation

The anterior band of the inferior glenohumeral ligament (IGHL) complex acts as a hammock. It is the primary static restraint to anterior translation when the shoulder is in 90 degrees of abduction and externally rotated.

Question 91

A 32-year-old baseball pitcher presents with posterior shoulder pain. MRI reveals a large paralabral cyst in the spinoglenoid notch. Which isolated physical exam finding is most likely to be present?

Explanation

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

Question 92

In the evaluation of glenohumeral instability, which of the following precisely describes an ALPSA lesion?

Explanation

An ALPSA (Anterior Labroligamentous Periosteal Sleeve Avulsion) lesion occurs when the anterior labrum detaches with the anterior periosteum and displaces medially along the glenoid neck, often healing in a non-anatomic position.

Question 93

During arthroscopic rotator cuff repair, a double-row transosseous-equivalent (suture bridge) technique is utilized. Which of the following best describes the primary biomechanical advantage of this construct?

Explanation

The transosseous-equivalent (suture bridge) technique maximizes the pressurized contact area between the rotator cuff tendon and its anatomic footprint. This optimizes the biological environment for healing.

Question 94

A 40-year-old male sustains a massive rotator cuff tear involving the subscapularis and supraspinatus. If the subscapularis is deemed chronically irreparable and atrophic, which tendon transfer is indicated?

Explanation

A pectoralis major transfer (typically routed subcoracoid or subclavicular) is the most utilized tendon transfer for an irreparable subscapularis tear. It restores dynamic anterior stability and internal rotation function.

Question 95

What is considered a critical contraindication to performing a latissimus dorsi tendon transfer for an irreparable posterosuperior rotator cuff tear?

Explanation

A latissimus dorsi transfer relies heavily on an intact or repairable subscapularis to maintain a balanced transverse force couple. An irreparable subscapularis tear is a strict contraindication to this procedure.

Question 96

The "remplissage" procedure is often performed as an adjunct to an arthroscopic Bankart repair. Which of the following correctly describes the technical execution of this procedure?

Explanation

The remplissage procedure involves suturing the infraspinatus tendon and posterior capsule into an engaging Hill-Sachs defect. This converts it to an extra-articular lesion, preventing it from engaging the anterior glenoid rim.

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

ABOS Shoulder MCQs (Set 3): Rotator Cuff & Glenoid Instability | OITE & Board Prep

Key Takeaway

ABOS Shoulder MCQs (Set 3): Rotator Cuff & Glenoid Instability | OITE & Board Prep

Chapter Index