Question 1

Following two previous shoulder stabilization procedures for recurrent dislocations, a 45-year-old man complains of pain and limited motion. Examination reveals increased passive external rotation and an inability to lift the back of the hand away from his back. Which of the following muscles is injured:

Explanation

The patient has an incompetent subscapularis muscle. An inability to lift the back of the hand away from the back (a positive Liftoff test) has been described by Gerber and colleagues and is a reliable method of evaluating subscapularis integrity. Patients with subscapularis tears often demonstrate an increase in passive external rotation and weakness in internal rotation.

Question 2

Which of the following is not a cause of failure following arthroscopic subacromial decompression:

Explanation

Causes of failure following arthroscopic decompression are similar to the causes of failure following open acromioplasty. Numerous studies have documented errors in diagnosis as the most common cause of failure. Inadequate bone resection can also cause continued pain and dysfunction. A retained coracoacromial ligament attachment can decrease the volume in the subacromial space and lead to recurrent impingement. Although bursal tissue can reconstitute following partial excision, this has not been shown as a common cause of failure following decompression. Deltoid detachment may cause weakness and pain.

Question 3

Which of the following structures is involved in the â essential lesionâ of a stiff shoulder:

Explanation

The long head of the biceps tendon defines the region of the rotator interval, which is the area between the anterior edge of the supraspinatus tendon and the superior edge of the subscapularis tendon. This region usually is contracted in individuals who lack external rotation of the adducted shoulder. Coracohumeral ligament contracture is an important component of adhesive capsulitis.

Question 4

A 35-year-old businessman sustains a type III acromioclavicular (AC ) separation of his dominant shoulder. Preferred treatment should be:

Explanation

Long-term outcome studies have demonstrated good and excellent results following symptomatic, nonsurgical treatment of grade I-III acromioclavicular separations. Surgical treatment may lead to complications (especially with the use of transfixing smooth pins), loss of reduction, and chronic pain due to joint instability.

Question 5

Which of the following muscles is most responsible for deceleration of the arm during pitching:

Explanation

During the deceleration phase, the excess kinetic energy that was not transferred to the ball is dissipated by controlled deceleration of the upper extremity. The rotator cuff (primarily teres minor) is the principle decelerator and is susceptible to tensile failure from eccentric loading.

Question 6

Which of the following conditions most often accompanies a dislocation of the longhead of the biceps tendon?

Explanation

Although isolated ruptures of the biceps tendon have been described, most cases involving biceps tendon pathology are accompanied by rotator cuff injury. When computerized tomography arthrograms are performed on patients who have clinical criteria for isolated ruptures of the long head of the biceps, the incidence of isolated lesions decreases to 6%. Although primary bicipital tendinitis was recognized as a frequent cause of anterior shoulder pain in the 1950s, it is currently a diagnosis of exculsion that is made far less frequently.

Question 7

Which of the following combinations correctly describes the contributions of the acromioclavicular ligaments and coracoclavicular ligaments in stabilizing the acromioclavicular joint:

Explanation

Fuduka and colleagues have studied the individual ligamentous contributions to acromioclavicular stability by performing load displacement tests on sectioned cadaveric models. These experiments led to the conclusion that the horizontal stability of the acromioclavicular joint is controlled by the acromioclavicular ligament and vertical stability is controlled by the coracoclavicular ligament.

Question 8

Which of the following statements is true concerning the bands of the anterior cruciate ligament:

Explanation

The anterior cruciate ligament is composed of at least two functional bands. The larger anteromedial band is tightest in flexion and loosest in extension. The smaller posterolateral band is tightest in extension and loosest in flexion. Conventional anterior cruciate ligament reconstruction replaces only the anteromedial band.

Question 9

Which of the following statements is true concerning the bands of the posterior cruciate ligament:

Explanation

The posterior cruciate ligament is composed of two functional bands. The larger anterolateral band is tightest in flexion and loosest in extension. The smaller posteromedial band is tightest in extension and loosest in flexion. Conventional posterior cruciate ligament reconstruction replaces only the anterolateral band.

Question 10

The most sensitive test for posterior cruciate ligament injury is the:

Explanation

All of the above tests have been described for evaluating posterior cruciate ligament injury. Of these tests, the posterior drawer test is the most sensitive(95%).

Question 11

A 30-year-old male avid runner presents with a 2-week history of right lateral knee pain. He denies any history of trauma, swelling, or mechanical symptoms. The pain only occurs with running and is relieved by cessation of activity. Physical examination does not demonstrate any effusion, and there is no pathologic laxity of the collateral or cruciate ligaments. There is tenderness to palpation along the lateral aspect of the knee that is most severe over the lateral epicondyle, particularly with the knee flexed to 30°. The next most appropriate course of action is:

Explanation

The patient has iliotibial band friction syndrome, which is common in runners. Physical therapy is successful in the majority of patients. Rarely, debridement of an ellipse of the iliotibial band will be required to provide relief.

Question 12

This radiograph shows a diaphysis of a 21-year-old female collegiate soccer player. She reports pain in the midshaft of her tibia for 7 months. She has been previously treated with cessation of soccer, 8 weeks in a short leg cast, and 3 months of treatment with an ultrasonic bone stimulator. Recommended treatment at this time should include:

Explanation

The tibia is the bone most prone to stress fractures in athletes. The appearance of the "dreaded black line" is a poor prognostic indicator for Orthopedic Prometric Exam Chapter 3 Image

Orthopedic Prometric Exam Chapter 3 Image

healing. Since this patient has failed nonoperative treatment, insertion of a reamed intramedullary nail would offer her the best chance of healing and earlier return to activity.

Question 13

A "stinger" (transient weakness of the upper extremity commonly seen after a blow to the head and shoulder in football) most commonly affects the:

Explanation

"Stingers" are common in football. They generally result from a transient stretch to the C -5/C -6 nerve roots resulting in temporary loss of strength of the biceps, deltoid, and spinatus muscles. It is generally safe to allow the athlete to return to participation, provided the cervical spine examination is normal and any neurological deficits have completely resolved.

Question 14

A 16-year-old male high school football player was making a tackle when he felt sudden pain in his right long finger. He has swelling and tenderness along the volar aspect of the injured digit. He is unable to actively flex the distal interphalangeal joint of the injured digit. Radiographs are negative for fracture. Recommended treatment should include:

Explanation

Avulsion of the flexor digitorum profundus, or "jersey finger," is a common injury in football. Appropriate treatment includes surgical repair.

Question 15

C atastrophic cervical spine injuries occurring during contact sports are most commonly a result of:

Explanation

Catastrophic injury of the cervical spine resulting in paralysis or death usually occurs from an axial loading mechanism, such as "spear" tackling in football. C ontroversy exists as to whether cervical spinal stenosis is a predisposing factor for catastrophic cervical spine injuries.

Question 16

A collegiate level sprinter sustains an acute nondisplaced fracture at the proximal metaphyseal-diaphyseal junction of the fifth metatarsal. Appropriate treatment for early return to play includes:

Explanation

Fractures of the metaphyseal-diaphyseal junction of the fifth metatarsal base, the Jones fracture, is treated more aggressively than its avulsed counterpart. In the acute situation, these fractures are treated in a non-weightbearing cast until union is obtained. Occasionally, an elite athlete will sustain a Jones fracture. It is important to determine whether this represents an acute injury or a stress fracture. Stress fractures are treated initially with non-weightbearing until union occurs and symptoms resolve. Acute Jones fractures in the athlete are best treated with compression screw fixation with bone graft to insure healing in a timely manner.

Question 17

This is the radiograph of a right hand dominant 15-year-old baseball player who felt a pop when swinging a bat. There is pain in the upper portion of the first rib. Recommended treatment should consist of:

Explanation

First rib fractures in athletes are rare. These fractures are thought to be stress fractures, usually occurring in pitchers. Treatment is observation until the fracture is healed.

Question 18

A 10-year-old female gymnast twists her knee on her dismount from the balance beam. She hears a pop and has immediate swelling. She is unable to continue with activity. Physical examination reveals a positive Lachman test and positive pivot shift. She has no joint line tenderness. Radiographs are normal. After an initial period of ice and range of motion exercises, recommended treatment should include:

Explanation

Anterior cruciate ligament injuries in children represent a vexing clinical problem. Standard anterior cruciate ligament reconstructions would involve drilling across an open physis, which may cause a growth disturbance. Results of direct repair or extra-articular reconstruction have been no better in children than in adults. The most reasonable initial treatment is rehabilitation. If despite adequate rehabilitation, the child continues to have instability, it is recommended that the child discontinues the activities that result in instability until skeletal maturity when a standard reconstruction can be performed, or when the child undergoes a physeal sparing reconstruction (i.e., Bergfeld's "tomato stake" reconstruction).

Question 19

The most common location of osteochondritis dissecans in the knee is the:

Explanation

Osteochondritis dissecans affects adolescents, and the knee joint is the most commonly affected joint. The most common location in the knee is the lateral aspect of the medial femoral condyle at the intercondylar notch. Treatment varies with the stability of the lesion from observation to operative reduction and fixation.

Question 20

A 15-year-old female volleyball player twisted her knee while planting her foot. She states she felt her knee give out. She had immediate swelling and was unable to continue participation. She denies hearing a pop. Physical examination reveals a large effusion with a range of motion from full extension to 80° flexion. She has marked tenderness along the medial retinaculum of her knee. She has no joint line tenderness. There is no pathologic laxity involving the collateral or cruciate ligaments. The most likely diagnosis is:

Explanation

Patellar subluxation is a common injury in athletes. It generally presents with a large effusion. Patients usually have a limited arc of motion but can usually obtain full extension. In addition to medial retinacular tenderness, patients will have apprehension to attempts at lateral displacement of the patella. Treatment is initially nonoperative, emphasizing quadriceps strengthening. Operative treatment is reserved for patients with continued instability despite appropriate rehabilitation.

Question 21

A 55-year-old man presents with anterior shoulder pain and increased passive external rotation after a heavy fall. Examination reveals a positive belly-press test and an inability to maintain internal rotation against resistance. Which structure is most likely injured?

Explanation

The subscapularis is the primary internal rotator of the shoulder. A positive belly-press test and an abnormal increase in passive external rotation strongly indicate a subscapularis tendon rupture.

Question 22

In a patient diagnosed with idiopathic adhesive capsulitis, contracture of which of the following specific structures is primarily responsible for the severe restriction of external rotation when the arm is adducted at the side?

Explanation

The coracohumeral ligament (CHL) is a primary component of the rotator interval. Contracture of the CHL specifically limits external rotation when the arm is adducted at the side, which is a hallmark clinical finding in frozen shoulder.

Question 23

During shoulder arthroscopy for a suspected SLAP lesion, the surgeon notes peeling back of the superior labrum when the arm is placed in abduction and external rotation. This "peel-back" mechanism is most commonly associated with which type of SLAP tear?

Explanation

The "peel-back" mechanism is the classic pathomechanical sign of a Type II SLAP tear. In this lesion, the superior labrum and biceps anchor are detached from the superior glenoid tubercle.

Question 24

In the context of severe proximal humerus fractures, which of the following vessels provides the dominant blood supply to the humeral head, thereby placing it at high risk of avascular necrosis if disrupted?

Explanation

Recent quantitative anatomical studies have demonstrated that the posterior circumflex humeral artery provides the dominant blood supply to the humeral head (approximately 64%). This contrasts with older texts that heavily emphasized the anterior circumflex humeral artery.

Question 25

A 25-year-old cyclist falls directly onto his shoulder point. Radiographs reveal a 150% superior displacement of the distal clavicle relative to the acromion, with marked widening of the coracoclavicular space. What is the most appropriate classification and typical initial management recommendation?

Explanation

A Type V AC joint injury involves 100-300% superior displacement of the clavicle due to complete disruption of the AC and CC ligaments along with the deltotrapezial fascia. Operative management is typically recommended to restore anatomy and function.

Question 26

A 19-year-old football player sustains a direct compressive blow to the medial clavicle. He presents with shortness of breath, dysphagia, and a palpable defect at the medial clavicle. Which imaging modality is considered the gold standard for accurately evaluating this injury?

Explanation

The clinical presentation is highly suspicious for a posterior sternoclavicular joint dislocation, a true orthopedic emergency. A CT scan of the chest is the gold standard to evaluate the dislocation and identify potential compression of vital mediastinal structures.

Question 27

A 32-year-old elite volleyball player presents with isolated weakness in external rotation of the shoulder. Examination reveals atrophy of the infraspinatus fossa, but supraspinatus strength and bulk are perfectly normal. Where is the most likely site of nerve entrapment?

Explanation

Entrapment of the suprascapular nerve at the spinoglenoid notch selectively denervates only the infraspinatus muscle, causing isolated external rotation weakness. Proximal entrapment at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 28

A 28-year-old pitcher complains of poorly localized posterolateral shoulder pain and paresthesias. Angiography reveals dynamic occlusion of the posterior circumflex humeral artery with the arm in extreme abduction and external rotation. Which nerve is most likely concurrently compressed in this specific anatomical syndrome?

Explanation

Quadrilateral space syndrome involves the dynamic compression of the axillary nerve and the posterior circumflex humeral artery within the quadrilateral space. It classically presents with vague posterior shoulder pain and paresthesias in the axillary nerve distribution.

Question 29

A 22-year-old rugby player with recurrent anterior shoulder instability is found to have 25% anterior glenoid bone loss. An open Latarjet procedure is planned. During the surgical approach to the anterior glenoid, which muscle's tendon is classically split horizontally?

Explanation

During the Latarjet procedure, the subscapularis tendon and muscle belly are split longitudinally (horizontally relative to the fibers) at the junction of the upper two-thirds and lower one-third. This provides optimal access to the anterior glenoid neck.

Question 30

A professional baseball pitcher demonstrates a 25-degree loss of internal rotation in his throwing shoulder compared to his contralateral shoulder, but his total arc of motion (internal + external rotation) remains completely symmetric. What is the most appropriate initial management?

Explanation

Glenohumeral internal rotation deficit (GIRD) in overhead athletes is primarily a result of posterior capsular contracture. When the total arc of motion is preserved, the standard initial management is a dedicated posterior capsular stretching program, such as "sleeper stretches".

Question 31

A 45-year-old man feels a sudden pop in his anterior elbow while lifting heavy machinery. He exhibits profound weakness in forearm supination and a positive Hook test. If the surgeon utilizes a single-incision anterior approach for distal biceps repair, which nerve is at greatest risk of iatrogenic injury from lateral retraction?

Explanation

During a single-incision anterior approach to the elbow, aggressive lateral placement of retractors places the radial nerve and its deep branch, the posterior interosseous nerve (PIN), at significant risk of neuropraxia or transection.

Question 32

A 50-year-old woman presents with numbness in her ring and small fingers. Examination reveals a positive Froment sign when asked to pinch a piece of paper. Which of the following muscles is actively compensating to cause the typical interphalangeal flexion seen in a positive Froment sign?

Explanation

A positive Froment sign indicates ulnar nerve palsy affecting the adductor pollicis. To maintain pinch grip, the patient compensates by firing the anterior interosseous nerve (AIN)-innervated flexor pollicis longus (FPL), resulting in hyperflexion of the thumb interphalangeal joint.

Question 33

Which of the following specific combinations of injuries definitively constitutes the "terrible triad" of the elbow?

Explanation

The terrible triad of the elbow is characterized by a posterior elbow dislocation associated with a radial head fracture and a coronoid process fracture. This complex injury pattern severely compromises both primary and secondary stabilizers of the elbow.

Question 34

A 35-year-old man complains of his elbow "clicking" and giving way when pushing himself up from a chair. Examination reveals a positive lateral pivot-shift test of the elbow. Which ligament is primarily incompetent in this condition?

Explanation

Posterolateral rotatory instability (PLRI) is caused by an insufficiency of the lateral ulnar collateral ligament (LUCL). The diagnosis is clinically confirmed by a positive lateral pivot-shift test showing subluxation with axial load, supination, and valgus stress.

Question 35

A 42-year-old carpenter presents with chronic medial elbow pain that drastically worsens with resisted wrist flexion and forearm pronation. If non-operative management fails and surgical debridement is required, which tendinous structure is the primary anatomical site of pathology?

Explanation

Medial epicondylitis (golfer's elbow) involves angiofibroblastic hyperplasia of the common flexor origin. It most consistently and primarily involves the origins of the pronator teres and the flexor carpi radialis tendons.

Question 36

A 22-year-old professional baseball pitcher presents with posterior shoulder pain during the late cocking phase of throwing. Examination reveals a 20-degree loss of internal rotation compared to the contralateral side. What is the most likely pathophysiology of his condition?

Explanation

This describes internal impingement, common in overhead athletes. It involves the undersurface of the supraspinatus and infraspinatus impinging against the posterosuperior glenoid and labrum during extreme abduction and external rotation.

Question 37

A 30-year-old weightlifter presents with vague posterior shoulder pain and paresthesias over the lateral deltoid. MRI demonstrates isolated fatty infiltration and atrophy of the teres minor muscle. The affected nerve is compressed in a space defined by which of the following boundaries?

Explanation

Quadrilateral space syndrome involves compression of the axillary nerve and posterior humeral circumflex artery. The boundaries are the teres minor (superior), teres major (inferior), long head of triceps (medial), and surgical neck of the humerus (lateral).

Question 38

A 32-year-old man presents with anterior shoulder pain and a sensation of giving way after a traumatic dislocation. MRI arthrogram reveals a J-sign with extravasation of contrast into the axillary pouch. Which of the following best describes this lesion?

Explanation

A Humeral Avulsion of the Glenohumeral Ligament (HAGL) typically presents with a J-sign on MRI, showing contrast extravasating into the axillary pouch due to tearing of the IGHL from its humeral insertion.

Question 39

A 25-year-old overhead athlete presents with deep shoulder pain and a positive O'Brien test. An MRI is obtained.

What is the most appropriate management for an isolated Type II SLAP tear in a young, high-level throwing athlete who has failed nonoperative treatment?

Explanation

In young, competitive overhead throwing athletes, arthroscopic SLAP repair is generally favored to restore the native anatomy and tension. Biceps tenodesis is highly successful but often reserved for older patients or non-throwers due to a lower complication rate.

Question 40

In the Latarjet procedure for anterior shoulder instability, the transferred coracoid process provides stability through a 'sling effect'. Which of the following structures is responsible for this dynamic sling effect?

Explanation

The Latarjet procedure provides dynamic stability via the 'sling effect' of the conjoined tendon (short head of biceps and coracobrachialis) acting across the anteroinferior capsule when the arm is abducted and externally rotated.

Question 41

A 35-year-old volleyball player has persistent shoulder weakness. MRI reveals a paralabral cyst at the spinoglenoid notch compressing a nerve. Which of the following clinical findings is expected?

Explanation

Compression of the suprascapular nerve at the spinoglenoid notch affects only the motor branches to the infraspinatus, leading to isolated infraspinatus atrophy. Compression at the suprascapular notch affects both the supraspinatus and infraspinatus.

Question 42

A 50-year-old construction worker presents with weakness in internal rotation and a positive belly-press test following a lifting injury 8 months ago. MRI shows a massive, retracted, irreparable tear of the subscapularis with severe fatty infiltration. Which tendon transfer is most appropriate?

Explanation

The pectoralis major transfer is the standard tendon transfer used to reconstruct an irreparable subscapularis tear, providing an anterior vector to restore internal rotation and dynamic anterior stability.

Question 43

A 60-year-old man complains of profound weakness in shoulder elevation and external rotation. Imaging reveals an irreparable massive tear of the supraspinatus and infraspinatus with an intact subscapularis. There is no significant glenohumeral arthritis. Which of the following tendon transfers is best indicated?

Explanation

A latissimus dorsi (or lower trapezius) transfer is indicated for younger, active patients with massive, irreparable posterosuperior rotator cuff tears (supraspinatus/infraspinatus) who have an intact subscapularis and lack advanced arthritis.

Question 44

According to the Rockwood classification of acromioclavicular (AC) joint injuries, what defines a Type V injury?

Explanation

A Type V AC joint injury involves disruption of the AC and CC ligaments with >100% (often 100-300%) superior displacement of the distal clavicle and severe stripping of the deltotrapezial fascia from the clavicle and acromion.

Question 45

During anterior portal placement in shoulder arthroscopy, the musculocutaneous nerve is at risk if instruments are directed too far medially and inferiorly. The safe zone is determined by the nerve's entry into the conjoined tendon, which is typically located how far distal to the tip of the coracoid process?

Explanation

The musculocutaneous nerve typically enters the conjoined tendon (coracobrachialis) approximately 5 to 8 cm distal to the tip of the coracoid process. Working too medially or inferiorly to the coracoid increases the risk of injury.

Question 46

A 28-year-old bodybuilder feels a sudden pop in his anterior chest while performing a bench press. Examination reveals loss of the anterior axillary fold and weakness in shoulder adduction and internal rotation. What is the most common anatomical site of this rupture?

Explanation

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

Question 47

In the pathogenesis of primary adhesive capsulitis, synovial inflammation progresses to capsular fibrosis. Which of the following cytokines is considered the primary driver of this fibrotic process?

Explanation

Transforming growth factor-beta (TGF-β) is widely recognized as a key profibrotic cytokine driving the fibroblastic proliferation and collagen deposition characteristic of the later stages of adhesive capsulitis.

Question 48

During arthroscopic evaluation of a stiff shoulder, a key anatomic structure is targeted for release.

Which structure forms the roof of the rotator interval and is typically contracted in adhesive capsulitis, limiting external rotation in adduction?

Explanation

The coracohumeral ligament (CHL) is the roof of the rotator interval. Its contracture is the 'essential lesion' in adhesive capsulitis, strictly limiting external rotation when the arm is adducted.

Question 49

A 45-year-old man experiences a seizure and subsequently presents with his shoulder locked in internal rotation. Radiographs demonstrate a 'lightbulb' sign on the AP view. What is the most likely associated osseous defect?

Explanation

The patient has a posterior shoulder dislocation (locked in internal rotation, 'lightbulb' sign). The classic osseous defect is the reverse Hill-Sachs lesion, which is an impaction fracture of the anteromedial humeral head.

Question 50

A 13-year-old baseball pitcher presents with vague proximal arm pain during throwing. Radiographs reveal widening and lateral fragmentation of the proximal humeral physis. What is the most appropriate initial management?

Explanation

Little League Shoulder is a proximal humeral epiphysiolysis caused by repetitive rotational stress. The standard treatment is immediate cessation of throwing (rest) for several months, followed by a gradual return-to-throwing program.

Question 51

Which of the following physical examination tests is most specific for diagnosing a tear involving the upper border of the subscapularis tendon?

Explanation

The bear hug test is considered the most sensitive and specific test for detecting upper subscapularis tendon tears, which are often missed by the lift-off and belly-press tests that evaluate the mid and lower portions of the muscle.

Question 52

A 21-year-old gymnast presents with painless winging of the scapula after a neck injury. Examination shows the vertebral border of the scapula translated laterally and superiorly. Which nerve is most likely injured?

Explanation

Lateral winging of the scapula (scapula is displaced laterally and superiorly) is caused by trapezius paralysis due to a spinal accessory nerve injury. Medial winging is caused by serratus anterior paralysis (long thoracic nerve).

Question 53

A 35-year-old male presents with acute, severe, unrelenting unilateral shoulder pain lasting several weeks, followed by patchy weakness in his periscapular muscles. MRI of the shoulder is unremarkable. What is the most likely diagnosis?

Explanation

Parsonage-Turner syndrome (idiopathic brachial neuritis) classically presents with an acute onset of severe, unrelenting shoulder pain lasting days to weeks, which is followed by profound weakness and atrophy as the pain subsides.

Question 54

In the evaluation of recurrent anterior glenohumeral instability, critical glenoid bone loss often dictates the need for a bony augmentation procedure (e.g., Latarjet) rather than an isolated soft-tissue Bankart repair. The universally accepted threshold for 'critical' bone loss is greater than:

Explanation

Bone loss greater than 20% to 25% of the inferior glenoid width is considered critical. Soft tissue repairs in this setting have an unacceptably high failure rate, making bony augmentation the standard of care.

Question 55

The long head of the biceps tendon is stabilized at the entrance to the bicipital groove by the biceps reflection pulley. Which of the following capsuloligamentous structures are the primary components of this pulley system?

Explanation

The biceps reflection pulley is primarily formed by the coracohumeral ligament (CHL) and the superior glenohumeral ligament (SGHL), which create a sling that keeps the biceps tendon centered in its groove.

Question 56

A 45-year-old manual laborer presents with persistent anterior shoulder pain. MRI confirms a Type II SLAP lesion. What is the most appropriate surgical management for this patient considering his age and occupation?

Explanation

In patients over 40 years of age, especially manual laborers, biceps tenodesis provides superior clinical outcomes and lower revision rates compared to SLAP repair. SLAP repair in older patients has a high risk of postoperative stiffness and persistent pain.

Question 57

A 22-year-old collegiate baseball pitcher reports posterior shoulder pain during the late cocking phase of throwing. The 'internal impingement' test is positive. What is the primary pathophysiological mechanism of this condition?

Explanation

Internal impingement typically occurs in overhead athletes during maximal external rotation and abduction (late cocking phase). It is caused by the articular surface of the posterior rotator cuff abutting the posterosuperior glenoid and labrum.

Question 58

A patient undergoes a Latarjet procedure for recurrent anterior shoulder instability. Postoperatively, he presents with profound weakness in elbow flexion and forearm supination, along with numbness over the lateral aspect of the forearm. Which structure was most likely injured during the procedure?

Explanation

The musculocutaneous nerve enters the coracobrachialis 5-8 cm distal to the coracoid tip and is at high risk during coracoid transfer procedures. Injury results in biceps/brachialis weakness and lateral forearm paresthesia.

Question 59

A 23-year-old rugby player has recurrent anterior shoulder dislocations. Advanced imaging reveals 12% anterior glenoid bone loss and a Hill-Sachs lesion that is determined to be 'off-track'. What is the most appropriate surgical intervention?

Explanation

For patients with subcritical glenoid bone loss (typically <15-20%) but an engaging or 'off-track' Hill-Sachs lesion, an arthroscopic Bankart repair combined with a remplissage (infraspinatus tenodesis) is the procedure of choice to prevent engagement.

Question 60

A 28-year-old elite volleyball player presents with isolated weakness in shoulder external rotation. MRI reveals a paralabral cyst causing nerve compression. Where is the cyst most likely located?

Explanation

Compression of the suprascapular nerve at the spinoglenoid notch affects only the infraspinatus, leading to isolated external rotation weakness. Compression at the suprascapular notch would affect both the supraspinatus and infraspinatus.

Question 61

A 35-year-old man presents with poorly localized posterior shoulder pain and numbness over the lateral deltoid. MRI shows isolated atrophy of the teres minor. Which of the following defines the superior border of the anatomical space involved in this syndrome?

Explanation

The patient has Quadrilateral Space Syndrome, compressing the axillary nerve and posterior humeral circumflex artery. The boundaries are the teres minor (superior), teres major (inferior), long head of triceps (medial), and surgical neck of humerus (lateral).

Question 62

During a physical examination for a suspected rotator cuff tear, the examiner places the patient's palm on their contralateral shoulder and asks the patient to resist an anteriorly directed force applied to the hand. What is this test, and which specific muscle portion does it evaluate?

Explanation

The Bear hug test evaluates the subscapularis and is particularly sensitive for tears of the upper portion of the subscapularis tendon. The belly-press test better isolates the lower subscapularis.

Question 63

A 65-year-old active man presents with severe shoulder pain and stiffness. Radiographs demonstrate advanced glenohumeral osteoarthritis. Physical exam and MRI confirm an intact and fully functional rotator cuff. What is the most appropriate surgical option?

Explanation

In a patient with advanced glenohumeral osteoarthritis and a definitively intact, functioning rotator cuff, anatomic total shoulder arthroplasty provides the best outcomes for pain relief and functional restoration.

Question 64

A 30-year-old bodybuilder feels a sudden 'pop' in his chest while performing a heavy bench press. Examination reveals loss of the anterior axillary fold contour and weakness in internal rotation. Which anatomical structure is most commonly ruptured in this scenario?

Explanation

Pectoralis major ruptures most commonly occur in weightlifters (e.g., bench pressing) and typically involve the sternocostal head avulsing from its insertion on the proximal humerus.

Question 65

Which of the following is considered the primary pathological change occurring during the 'freezing' stage of idiopathic adhesive capsulitis?

Explanation

Adhesive capsulitis is characterized by intense synovial inflammation followed by capsular fibrosis. The core pathological finding is thickening and contracture of the rotator interval and the coracohumeral ligament.

Question 66

A 25-year-old cyclist falls directly onto his shoulder. Radiographs show a 100% superior displacement of the distal clavicle relative to the acromion. The coracoclavicular distance is increased by 50% compared to the contralateral side. What is the generally accepted initial management?

Explanation

This is a Rockwood Type III acromioclavicular joint separation. Most literature supports initial non-operative management for Type III injuries, as functional outcomes are typically equivalent to surgery without the associated surgical risks.

Question 67

Following an extensive axillary lymph node dissection, a patient presents with medial winging of the scapula, which is accentuated when the patient pushes against a wall. Which muscle and corresponding nerve have been injured?

Explanation

Medial winging of the scapula is caused by weakness of the serratus anterior muscle, which is innervated by the long thoracic nerve. This nerve is particularly vulnerable during axillary surgeries.

Question 68

An 18-year-old is involved in a high-speed motor vehicle accident and presents with severe chest pain, dyspnea, and dysphagia. Exam reveals a palpable defect at the medial end of the right clavicle. What is the best initial diagnostic imaging and definitive treatment if closed reduction fails?

Explanation

Posterior sternoclavicular dislocations are orthopedic emergencies due to the risk to mediastinal structures. A CT scan is the best imaging modality. If closed reduction fails, open reduction must be performed with cardiothoracic backup due to the proximity of great vessels.

Question 69

A 72-year-old patient presents with a massive, irreparable rotator cuff tear and pseudoparalysis of the shoulder. Radiographs demonstrate an acromiohumeral distance of 2 mm and early 'acetabularization' of the acromion without glenohumeral arthritis. What is the Hamada classification and optimal treatment?

Explanation

Hamada Grade 3 is characterized by an acromiohumeral interval < 7mm with acetabularization of the acromion, but without significant glenohumeral arthritis. Reverse total shoulder arthroplasty is the treatment of choice for elderly patients with pseudoparalysis.

Question 70

A 40-year-old man falls on an outstretched hand, sustaining a 'terrible triad' injury of the elbow. Which of the following describes the recommended sequence of surgical reconstruction to restore stability?

Explanation

The standard surgical sequence for a terrible triad injury (elbow dislocation, radial head fracture, coronoid fracture) works deep to superficial: coronoid fixation, then radial head repair or replacement, followed by lateral collateral ligament (LCL) complex repair.

Question 71

A 21-year-old collegiate baseball pitcher complains of posteromedial elbow pain occurring primarily during the deceleration phase of throwing. Examination reveals a 15-degree flexion contracture and sharp pain with forced terminal extension. What is the most likely diagnosis?

Explanation

Valgus extension overload in throwers is caused by repetitive impingement of the posteromedial olecranon into the olecranon fossa, often leading to posteromedial osteophytes and pain with forced extension.

Question 72

A 13-year-old baseball pitcher presents with progressive shoulder pain during throwing. Radiographs show widening and sclerosis of the proximal humeral physis compared to the contralateral side. What is the most appropriate initial treatment?

Explanation

'Little Leaguer's shoulder' is a proximal humeral epiphysiolysis caused by repetitive rotational stress. The cornerstone of treatment is absolute rest from throwing for typically 3 months until clinically and radiographically healed.

Question 73

What is the most common cause of significant, permanent loss of external rotation following an open anterior shoulder stabilization procedure (such as a Putti-Platt or standard open Bankart)?

Explanation

Historically, non-anatomic anterior stabilizations like the Putti-Platt intentionally shortened the subscapularis and anterior capsule, leading to an obligate loss of external rotation and subsequent posterior glenoid wear (capsulorrhaphy arthropathy).

Question 74

A 22-year-old gymnast complains of deep, poorly localized shoulder pain during overhead routines. An MR arthrogram demonstrates a superior labral tear that propagates into the biceps anchor, causing instability of the biceps-labral complex. Based on the Snyder classification, what type of SLAP lesion is this?

Explanation

A Snyder Type II SLAP lesion involves detachment of the superior labrum and the origin of the long head of the biceps tendon from the glenoid, resulting in instability of the biceps-labral anchor.

Question 75

A professional tennis player presents with vague shoulder aching. Physical examination demonstrates 20 degrees of internal rotation and 110 degrees of external rotation in 90 degrees of abduction. Which anatomical structure is primarily contracted, causing this Glenohumeral Internal Rotation Deficit (GIRD)?

Explanation

GIRD is heavily associated with overhead throwing or serving sports. The primary structural cause is a contracture and thickening of the posteroinferior capsule, often managed successfully with sleeper stretches.

Question 76

A 55-year-old man presents with severe shoulder pain and restricted external rotation 15 years after an open anterior shoulder stabilization (Putti-Platt procedure). Radiographs reveal severe glenohumeral osteoarthritis. What is the primary pathophysiological mechanism leading to this complication?

Explanation

Capsulorrhaphy arthropathy is a known complication of non-anatomic anterior stabilization procedures like the Putti-Platt, where excessive tightening of the anterior structures leads to obligatory posterior humeral head subluxation and subsequent arthritis.

Question 77

A 45-year-old woman with type 1 diabetes presents with progressive, painful restriction of both active and passive shoulder motion. During the early 'freezing' phase of this condition, histological analysis of the joint capsule would most likely demonstrate:

Explanation

Adhesive capsulitis is characterized by fibroblastic proliferation and increased type III collagen production. Cytokines such as TGF-beta and PDGF play a central role in driving this fibrotic cascade.

Question 78

A 40-year-old weightlifter presents with acute weakness in internal rotation and a positive bear-hug test after a heavy bench press. MRI confirms an isolated full-thickness tear of the subscapularis tendon. What associated structural pathology is most critical to evaluate and address during surgical repair?

Explanation

The subscapularis tendon, along with the coracohumeral ligament, forms the medial portion of the biceps pulley. A full-thickness subscapularis tear often compromises the pulley, leading to medial subluxation or dislocation of the biceps tendon.

Question 79

A 22-year-old collegiate baseball pitcher complains of posterior shoulder pain during the late cocking phase of throwing. Examination shows a loss of 25 degrees of internal rotation compared to the contralateral side, and pain is provoked with the shoulder abducted and externally rotated. What is the most likely diagnosis?

Explanation

Internal impingement occurs in overhead athletes when the posterosuperior rotator cuff impinges against the posterosuperior glenoid labrum in maximum abduction and external rotation. It is strongly associated with GIRD and posterior capsular contracture.

Question 80

A 24-year-old athlete with recurrent anterior shoulder instability undergoes preoperative evaluation.

Imaging reveals an anterior glenoid bone loss of approximately 30%. Which of the following is the most appropriate definitive management?

Explanation

In the setting of significant anterior glenoid bone loss (typically >20-25%), soft-tissue stabilization (Bankart repair) has a high failure rate. A bone-block augmentation, such as the Latarjet procedure, is indicated to restore glenoid tracking.

Question 81

A 28-year-old volleyball player presents with insidious onset of posterior shoulder pain and isolated weakness in external rotation. MRI reveals a paralabral cyst in the spinoglenoid notch. Which muscle is primarily affected by this cyst?

Explanation

A cyst at the spinoglenoid notch specifically compresses the suprascapular nerve after it has innervated the supraspinatus, leading to isolated denervation and atrophy of the infraspinatus muscle.

Question 82

A 65-year-old man presents with chronic shoulder pain, significant loss of active elevation (pseudoparalysis), and superior migration of the humeral head on radiographs. If an MRI confirms massive, irreducible tears of the supraspinatus and infraspinatus with grade 4 fatty infiltration, what is the best surgical option to restore function?

Explanation

Reverse total shoulder arthroplasty is the most reliable treatment for pseudoparalysis in an older patient with an irreparable posterosuperior rotator cuff tear. It medialize and distalizes the center of rotation, increasing the deltoid's moment arm.

Question 83

A 35-year-old man arrives at the emergency department with a locked shoulder after suffering a grand mal seizure.

He holds his arm in internal rotation and cannot externally rotate. Which of the following osseous lesions is most likely to be present?

Explanation

Seizures classically cause posterior shoulder dislocations due to the overpowering strength of the internal rotators. This results in an impaction fracture on the anteromedial aspect of the humeral head, known as a reverse Hill-Sachs or McLaughlin lesion.

Question 84

A 55-year-old laborer undergoes a massive, irreparable rotator cuff repair using a latissimus dorsi tendon transfer. For this transfer to be biomechanically effective and successful, which of the following prerequisites MUST be met?

Explanation

A latissimus dorsi transfer relies on restoring the anterior-posterior force couple. Therefore, a functional and intact anterior cuff (subscapularis) is an absolute prerequisite for a successful outcome.

Question 85

During a routine shoulder arthroscopy, the surgeon establishes the standard posterior portal approximately 2 cm inferior and 1 cm medial to the posterolateral corner of the acromion. If this portal is placed too inferiorly, which nerve is at greatest risk of injury?

Explanation

The axillary nerve runs inferior to the teres minor and traverses the quadrilateral space. Placing the posterior portal too far inferiorly places the axillary nerve at significant risk.

Question 86

A 60-year-old female undergoes arthroscopic release for recalcitrant adhesive capsulitis. Which anatomic structure must be released specifically to reliably restore external rotation with the arm at the side?

Explanation

Contracture of the coracohumeral ligament and the rotator interval is the primary pathology limiting external rotation in the adducted position in patients with adhesive capsulitis.

Question 87

A 30-year-old male sustains an acute, high-energy acromioclavicular joint separation. Radiographs demonstrate >100% superior displacement of the clavicle relative to the acromion, with significant posterior displacement into the trapezius fascia. What is the correct classification of this injury?

Explanation

In the Rockwood classification, a Type IV AC joint separation is characterized by posterior displacement of the distal clavicle into or through the trapezius fascia, which requires surgical intervention.

Question 88

A 14-year-old elite baseball pitcher presents with generalized shoulder pain and declining throwing velocity. Radiographs reveal widening and irregularity of the proximal humeral physis. What is the most appropriate initial management?

Explanation

This presentation is classic for 'Little Leaguer's Shoulder' (proximal humeral epiphysiolysis). It is a stress injury to the physis, and the mainstay of treatment is absolute rest from throwing until symptoms resolve and radiographs normalize.

Question 89

During an open anterior shoulder stabilization, a retractor is placed medially over the anterior aspect of the glenoid neck and conjoint tendon. The patient develops postoperative numbness over the lateral forearm and weakness in elbow flexion. Which nerve was most likely injured?

Explanation

The musculocutaneous nerve typically enters the coracobrachialis 5-8 cm distal to the coracoid process. Vigorous medial retraction on the conjoint tendon during open anterior shoulder surgery places this nerve at high risk of traction injury.

Question 90

A 27-year-old male presents to the trauma bay after a severe motor vehicle collision. He complains of chest pain, dysphagia, and shortness of breath. Examination reveals a painful, depressed sternoclavicular joint. What is the most appropriate next step in diagnostic imaging?

Explanation

Posterior sternoclavicular joint dislocations are orthopedic emergencies due to the risk of impingement on retrosternal structures (trachea, esophagus, great vessels). A CT scan is the gold standard for accurate diagnosis and evaluating associated visceral injuries.

Question 91

A 32-year-old bodybuilder feels a sudden 'pop' in his anterior chest wall while performing heavy bench presses. He has a loss of the anterior axillary fold and bruising over the medial arm. If operative repair is chosen, what is the anatomic footprint of the ruptured tendon?

Explanation

The pectoralis major tendon ruptures most commonly at its insertion onto the lateral lip of the bicipital groove of the humerus. Early surgical repair in active patients yields excellent functional results.

Question 92

A 65-year-old woman with a massive rotator cuff tear undergoes repair. Six weeks postoperatively, she exhibits profound, isolated weakness of the anterior deltoid and reports a sudden inability to actively elevate her arm after a minor fall, although passive elevation is preserved. An axillary nerve injury is ruled out. What surgical complication most likely occurred?

Explanation

Isolated, profound loss of active elevation with preserved passive motion following an open or mini-open cuff repair can indicate failure of the deltoid repair (avulsion from the acromion), a devastating complication resulting in catastrophic anterior deltoid failure.

Question 93

In evaluating a patient with scapulothoracic crepitus (snapping scapula syndrome), a palpable mass is felt at the superomedial angle of the scapula. What is the most common benign bone tumor responsible for this presentation?

Explanation

Osteochondroma is the most common benign bone tumor of the scapula and can cause snapping scapula syndrome by physically rubbing against the rib cage during scapulothoracic motion.

Question 94

A patient is evaluated for Parsonage-Turner syndrome (idiopathic brachial neuritis). Which of the following clinical patterns is the classic hallmark of this condition?

Explanation

Parsonage-Turner syndrome is characterized by the sudden onset of intense, unremitting shoulder and arm pain that lasts for a few weeks, followed closely by weakness, paralysis, and atrophy of the upper extremity muscles (often the rotator cuff or periscapular muscles).

Question 95

A 70-year-old woman sustains a 4-part proximal humerus fracture and undergoes a hemiarthroplasty. During the procedure, the tuberosities are reconstructed. What factor is most critical for achieving a good functional outcome regarding active elevation postoperatively?

Explanation

The functional success of hemiarthroplasty for a proximal humerus fracture is highly dependent on the secure fixation and anatomic healing of the tuberosities. Failure of tuberosity healing leads to superior migration of the prosthesis and poor active elevation.

Orthopedic Prometric MCQs - Chapter 3 Part 1

Orthopedic Prometric MCQs - Chapter 3 Part 39

Orthopedic Prometric MCQs - Chapter 3 Part 39

Chapter Index